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How many alcohol units do you consume per week? *

Are you receiving any medical treatment at the present time? *
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Have you been a patient in hospital during the past two years? *
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Have you taken any medicine, tablets, capsules or drugs during the past two years? *
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Have you experienced any allergies or unusual effects from any tablets, drugs, injections, or anaesthetic? *
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Are you or have you been under the care of a doctor during the past two years? *
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Have you ever had any of the following? If so, please tick as appropriate.

Are you HIV positive? *
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Have you had any prosthetic surgery? (e.g., Heart Valve or Hip replacement) *
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Do you have Dental pain or a Dental problem at present? *
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Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches? *
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Do you become anxious or uncomfortable when you are having dental treatment? *
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