Medical History Login Retrieve my history Patient Personal and Medical QuestionnairePlease answer the questions below as thoroughly as possible. It will greatly assist us to provide the best dental care and treatment for you.Name: * Mr Mrs Miss Ms Dr Other First name *Family name *Address *Suburb *Postcode *Date of Birth *Phone (Home)Phone (Mobile) *E-mail *OccupationWhom may we thank for your referral to our practice? Person/s responsible for payment of accounts? Which health fund do you belong to? Are you currently eligible for Government Subsidised Dental Health Care? Yes No If yes, please circle which one you or your child are eligible for: Health Care Card Pension Concession Veterans’ Affairs Child Dental Benefits Schedule Your dental care can be significantly effected by the state of your health. Please answer the below questions thoroughly or discuss them with your dentist: I have private and confidential medical matters that I wish to discuss with the dentist Yes No Are you receiving any medical treatment at present? Yes No Name of your medical practitioner/specialist Yes No Have you ever been in hospital? If yes, nature of hospitalisation and dates: Yes No Some medicines may interfere with your dental treatment or react with dental materials used by your dentist. Please provide details (including dose and frequency) of any medicine or medication that you are currently taking, or have been taking recently:Aspirin Warfarin/Heparin/Any blood thinner Oral contraceptive pill Hormone Replacement Therapy Cortisone or steroids Medication for depression (MAOIs, SSRIs or Tricyclics) Treatment for osteoporosis (Bisphosphonates, Prolia) Any herbal or naturopathic medications Any ‘over the counter’ or prescription medication If you are in any doubt, please bring your medication packet in to show your dentist.Do you have any allergies? i.e. latex, penicillin etc Yes No If yes, please provide details Do you currently, or have you ever suffered from any illness or infectious disease? Yes No If yes, please provide details and dates Do you, or have you ever smoked? Yes No Approx. quit date (if applicable) If yes, for how long? How much do you smoke? FEMALES : Are you pregnant? Yes No Are you breastfeeding? Yes No If yes, when are you due? Please indicate the reason for your visit and if any of the following procedures interest you:Cosmetic Dental TreatmentsComplete simple transformationDo You Have a Gummy Smile That You Wish to Address? Crowns/Bridges/Implants/Dentures Orthodontics/Braces/Invisalign Veneers/Teeth Whitening/Tooth Coloured Fillings General Dental Treatments General Dental TreatmentsCheck Up and Clean Head, Neck and Jaw Pain Management Root Canal Treatment Snoring and Sleep Apnoea Wisdom Teeth/Extractions DECLARATION:In signing this form I/we acknowledge that this represents an accurate medical history.I/we will advise my dentist of any changes to my medical history in the future. I/we understand that all medical details will be treated with complete professional confidentiality.Patient Signature: (Parent or guardian if under 18 years) * Signature confirmed Clear Date: Submit
