Medical History

PATIENT DETAILS

Title —Please choose an option—Mr.Mrs.Miss.Ms.Dr.

Surname

Given name

Date of birth

—Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Residental address

Suburb

State

Postcode

Postal address (if different)

Mobile (only numbers)

Home phone (only numbers)

Work Phone (only numbers)

Email

Occupation

Private Health Insurance

Medicare number

Emergency contact name

Emergency contact phone (only numbers)

Emergency contact relationship

MEDICAL HISTORY
Are you taking any medications (incl. dietary supplements)? —Please choose an option—No.Yes.

Have you ever had an adverse reaction to local anaesthetics or other medications? —Please choose an option—No.Yes.

Females, are you pregnant? —Please choose an option—No.Yes.

Have you ever smoked? —Please choose an option—No.Yes.

Have you ever had or are currently suffering from any of the following? AllergiesRheumatic FeverTyroids ProblemsHeart ComplaintsHigh Blood PressureOsteoporosis (Eg. CJD, TB, Staph, etc)RadiotherapyDiabetesStrokeAsthmaArti-cal JointCancerBleedingHIV InfectionHepatitisEpilepsyNone

If yes to any of the above, please give details

Is there anything else about your health you believe we should know about? —Please choose an option—No.Yes.

MEDICAL HISTORY
Last dental visit

Have you ever had a reaction or complication following dental treatment in the past? —Please choose an option—No.Yes.

Are you suffering from any of the following? Bad appearance of teethBad BreathBleeding gumsLost filling /cavityDry mouthGrindingMissing teethLoose teethDiscoloured teethWorn teethSensitive teethClicking of the jawDifficulty chewingRapid decaying teethWisdom tooth painNone

HOW DID YOU FIND ABOUT US?
GoogleLocation/SignageStaffInstagramFacebookWord-of-MouthSchool newsletterFlyer/BannerInsurance/Dental directoryAnother health provider

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