Free Online Smile Assessment
in Morden & Surbiton

Are you currently receiving treatment from a doctor, hospital or clinic?

Have you ever had treatment that required you to be in hospital?

Are you taking any regular/prescribed medication?

Do you have allergies to any medicines (e.g. antibiotics), substances (e.g. latex/rubber) or foods?

Do you suffer from hay fever or eczema?

Do you suffer from bone disease / arthritis?

Have you ever had a joint replacement or other implants?

Have you ever had heart problems, angina, blood pressure problems, stroke, pacemaker or heart surgery?

Do you have bronchitis, asthma or other chest condition?

Do you have diabetes?

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?

Have you ever suffered from liver disease (e.g. jaundice, hepatitis) or kidney disease?

Have you ever had rheumatic fever or chorea (St Vitus Dance)?

Have you ever had a bad reaction to general or local anaesthetic?

Do you get bruising or persistent bleeding following injury, tooth extraction or surgery?

Do you suffer from cold sores?

Have you ever had any other serious illness or infectious disease?

Have you ever had blood refused by the Blood Transfusion Service?

Have you ever had any infectious diseases including HIV or hepatitis?

Are you currently carrying a medical warning card?

Do you smoke / use electric cigarettes?

Do you use Chewing Tobacco / Paan / Supari?

Do you drink alcohol?

Are you pregnant or possibly pregnant?

Do you have a current occupation? (If yes, please specify below.)

Can you include emergency contact information if applicable (name and number).