HTML Preview Patient Medical History Form page number 1.
New Patient & Dental History Form
Please Turn Over
We are pleased to welcome you our practice. Please complete the form.
The following information is necessary to enable us to provide you with
your best dental care. All information disclosed is confidential.
PERSONAL DETAILS
First Name __________________________ Surname __________________________ Age ________ DOB _________________
Address __________________________________________________________________________________________________
Suburb _______________________________________________ Post Code ________________
Phone (Home) ___________________________________________ Phone (Mobile) ______________________________________
Occupation _______________________________________________________________________________________________
Email Address ______________________________________________________________________________________________
GP’s Name and Location ______________________________________________________________________________________
Health Fund (if applicable) ____________________________________________________________
If you are under 16, please name your parents/guardians _______________________________________________________________
HEALTH DETAILS
Do you have, or have you ever had any of the following conditions?
Allergies (eg. Penicillin, sulphur, codeine, latex)
Arthritis
Artificial Joints (eg. Hip or knee replacement)
Bone Disorders (eg. Osteoporosis, Pagets disease, cancer of bone)
Cancer or tumour
Diabetes
Epilepsy or other Neurological Disorder
Fainting or dizziness
Hepatitis B or C
HIV/AIDS
Heart Problems (eg. Heart attack, angina, stroke, murmur)
Heart Surgery (eg. By-pass, valve replacement, pacemaker)
High or low blood pressure
Kidney or liver disease
Mental health issues
Radiation to head or neck
Respiratory problems
Sinus problems
Have you ever taken a bisphonate? (eg. atonel, zometa, fosamax etc.)
Do you bruise or bleed easily after injury?
Do you smoke or use other forms of tobacco?
Are you, or suspect you may be pregnant?
List all medication or tablets you currently take _____________________________________________________________________
_________________________________________________________________________________________________________
Is there anything else you can tell us about your general health? _________________________________________________________
Yes No