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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
YesNo
Circulatory Problems
YesNo
Blood Pressure
YesNo
Radiation Treatment
YesNo
Artificial Joints
YesNo
Excessive Bleeding
YesNo
Rheumatic Fever
YesNo
Excessive Bruising
YesNo
Ulcers (stomach)
YesNo
Anaemia or other Blood Disorders
YesNo
Sinus Trouble
YesNo
Diabetes
YesNo
Artificial Heart Valves
YesNo
Asthma
YesNo
Infectious Diseases
YesNo
Hepatitis
YesNo
Allergies to Anaesthetics
YesNo
Epilepsy
YesNo
Allergies to Penicillin
YesNo
Liver or Kidney Problems
YesNo
Allergies to Medications
YesNo
Tumour/Cancer History
YesNo
Allergies to Latex
YesNo
Hormone Replacement Therapy
YesNo
Are you currently taking any drugs or medicines?
YesNo
Does your jaw "click" or hurt?
YesNo
List medications:
Do you feel you grind your teeth?
Have you ever had orthodontic treatment?
YesNo
Do you think you have occasional bad breath?
YesNo
Do you wear a dental night guard?
Do your gums ever bleed when you clean your teeth?
Have you ever had periodontal (gum) treatment?
YesNo
Do you experience sensitivity with hot/cold?
YesNo
Have you ever had your bite adjusted?
YesNo
Do your teeth ever hurt when you bite hard?
YesNo
Do you bite your lips or cheeks often?
YesNo
Does floss ever tear between your teeth?
YesNo
Do you smoke?
YesNo
Does food get jammed between your teeth?
YesNo
Amount per day:
YesNo
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?
Monthly3 Monthly6 MonthlyYearly2 YearlyGreater than 2 Yearly
Previous dental x-rays were taken
Less than 1 yearMore than 1 year
Are you pregnant?
YesNo
Due date