Medical History Form

Call us to book an appointment

Medical History Form

Call us to book an appointment

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:
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

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

Do you feel refreshed in the morning when you wake up?
YesNo


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:
List any medication you are currently taking:
GP's Name and location:
Signature:
Date: