Confidential Medical History Form

It is important for us to know details about your medical history as these could affect the success of your oral health care. The information provided is confidential and will be handled in accordance with our privacy policy.

First Name *

Last Name *

Date of Birth

Occupation *

Address *

Email *

Phone (Home)

Phone (Mobile)

Phone (Work)

Interests

Private Health Insurance *

Your Emergency Contacts

Emergency Contact Name *

Phone *

Relationship *

Doctor's Name *

Doctor's Phone *

Your Health

How happy are you with your smile? (Rate 1-10) *

1

2

3

4

5

6

7

8

9

10

Are you interested in whitening? *

Yes

No

If yes, please list *

Are you pregnant? *

Yes

No

If yes, when is the due date?

Any known allergies? *

Yes

No

If yes, please list

Any known reactions to anaesthesia? *

Yes

No

If yes, please list

Do you require antibiotic cover BEFORE dental treatment? *

Yes

No

Are you taking medication for bone disease? *

Yes

No

If yes, please list *

Current Medication

Please indicate if you have, or have you ever had any of the following medical conditions? *

Asthma

High | Low Blood Pressure

Smoker

Diabetes

Cold Sores

Excessive Bleeding

Hepatitis A | B | C

HIV | AIDS

Rheumatic Fever

Bronchitis, Emphysema or Lung Condition

Stroke

Tuberculosis

Heart Murmur

Heart Complaint

Cardiac Pace Maker

Heart Valve Disorder

Thyroid Disease

Kidney Disease

Epilepsy

Radiation Therapy

Radiation Therapy

Prosthetic Implant

Osteoporosis

Transplant: Organ | Marrow

Anaemia, Leukaemia or other Blood Diseases

Grinding / Clenching

Sleep Aids (e.g. CPAP)

Sleep Study

Snoring

Additional notes or condition

Referred By

Health Fund

TV Advert

Yellow Pages

Street Sign

Facebook

Google

Or Another Patient (Name)

Do you consent to your treatment discussions being recorded for treatment planning purposes? *

Yes

No