Medical History Form

Medical History Form

Contact Us

Please complete the following confidential questionnaire, which will assist us in providing you with quality dental care.

Please Select  :  
MrMrsMsMissMasterDr
Surname*:
First Name*:
Address:
Suburb:
Postcode:
Phone Home:
Work:
Mobile:
Email:
Date of Birth:
Occupation:
Parent/Guardian names if under the age of 16:
Are you in a Private Health Fund for Dental?
  YesNo

If yes, which one?  
Are you covered by Veterans Affairs?
  YesNo

If yes, card number?  
How did you find out about Our Practice?  
AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther
Have you ever had or do you have any of the following? (Please tick)
High Blood Pressure
YesNo

Diabetes
YesNo

Heart Conditions or Heart Surgery
YesNo

Artificial heart valve
YesNo

Damaged heart valve
YesNo

Penicillin allergy
YesNo

Latex allergy
YesNo

Kidney disease
YesNo

Arthritis
YesNo

Excessive Bleeding
YesNo

Asthma or Bronchitis (Which one?)
YesNo

Rheumatic Fever
YesNo

HIV or Hepatitis A,B or C (Which one?)
YesNo

Hip/Knee Replacement (Which one?)
YesNo

Epilepsy
YesNo

Anxiety or Depression (Which one?)
YesNo

Hay Fever or Sinus
YesNo

Allergies
YesNo

Ladies, are you pregnant?
YesNo

Radiation therapy to the head or neck
YesNo

Treatment therapy for cancer
YesNo

Do you get headaches?
YesNo

Do you breathe through your mouth?
YesNo

Do you clench or grind your teeth?
YesNo

Do you snore?
YesNo

Would you like to improve the colour of your teeth?
YesNo

Are you happy with your smile?
YesNo

Would you like to straighten your teeth or improve the appearance?
YesNo

Do you snore or have sleep apnoea?
YesNo

Have you taken bisphosphantes?
YesNo

Tuberculosis
YesNo

Any other serious illnesses not mentioned
YesNo

Do your gums bleed when brushing?
YesNo

Are your teeth sensitive to hot or cold when brushing?
YesNo

As part of our service to help you with dental treatment, we offer all our patients payment plans/finance plans through Smile RightTM.
I allow Family Dental Care to share my personal information with Smile RightTM.
YesNo

What is the reason for your visit today?
Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
Other serious injury or illness:
Are you currently taking any medications?

List any medication you are currently taking:

GP's Name and location:
Signature:
Date:
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COVID19 Safety Policy
All treatment carries risks. Individual consultation is required with one of our practitioners to ensure that the treatment is right for you. Any surgical or invasive procedure carries risks. Before proceeding you should seek a second opinion from an appropriately qualified health practitioner. Contact us for more information. Rebates may vary depending on your individual health fund.

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Last Update: November 2024
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