Medical History Form

So we can ensure we are looking after your needs, please review and complete the following questionnaire:

In accordance with the Privacy Act your details will be handled with utmost confidentiality and will not pass beyond this practice without your written consent.

 

( *Required Fields )

Title
Surname*
First Name*
Date of Birth*
Recommended by
Address*
Postcode*
Private Phone*
Mobile Phone*
Business Phone
Email*
Occupation
Person responsible for fees (if not self):
Address of fee payer*
Post Code*
Purpose of visit
Dental Insurance
Insurance provider
Policy Number
Is another member of your family a patient
at our office:
Name
Have you had any of the following?
Any Heart Problems
 Yes No
Circulatory Problems
 Yes No
Blood Pressure
 Yes No
Radiation Treatment
 Yes No
Artificial Joints
 Yes No
Excessive Bleeding
 Yes No
Rheumatic Fever
 Yes No
Excessive Bruising
 Yes No
Ulcers (stomach)
 Yes No
Anaemia or other Blood Disorders
 Yes No
Sinus Trouble
 Yes No
Diabetes
 Yes No
Artificial Heart Valves
 Yes No
Asthma
 Yes No
Infectious Diseases
 Yes No
Hepatitis
 Yes No
Allergies to Anaesthetics
 Yes No
Epilepsy
 Yes No
Allergies to Penicillin
 Yes No
Liver or Kidney Problems
 Yes No
Allergies to Medications
 Yes No
Tumour/Cancer History
 Yes No
Allergies to Latex
 Yes No
Hormone Replacement Therapy
 Yes No
Are you currently taking any drugs or medicines?
 Yes No
Does your jaw "click" or hurt?
 Yes No
List medications:
Do you feel you grind your teeth?
Have you ever had orthodontic treatment?
 Yes No
Do you think you have occasional bad breath?
 Yes No
Do you wear a dental night guard?
Do your gums ever bleed when you clean your teeth?
Have you ever had periodontal (gum) treatment?
 Yes No
Do you experience sensitivity with hot/cold?
 Yes No
Have you ever had your bite adjusted?
 Yes No
Do your teeth ever hurt when you bite hard?
 Yes No
Do you bite your lips or cheeks often?
 Yes No
Does floss ever tear between your teeth?
 Yes No
Do you smoke?
 Yes No
Does food get jammed between your teeth?
 Yes No
Amount per day:
 Yes No
Is there anything else you would like us to know?
The name of your physician
How long since you last dental appointment?
Address of physician
Post Code
Phone number
How often do you have dental examinations?
 Monthly 3 Monthly 6 Monthly Yearly 2 Yearly Greater than 2 Yearly
Previous dental x-rays were taken
 Less than 1 year More than 1 year
Are you pregnant?
 Yes No
Due date