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Medical History Form

Dental History Form

We would like to welcome you to Helena Street Dental. To assist us in providing you with the best possible treatment and standard of care, we ask that you complete this confidential medical history questionnaire

Title:

Name *

Surname

Middle Name

Date of Birth

Address

Suburb

State

Post Code

Home Phone

Mobile Number:

Work Phone:

Occupation:

Employer:

Email Address:

Health Insurance Fund:

What is your preference for communication from our practice?
 Home Phone Work Phone Mobile

How did you find out about us?
 Website Google Yellow Pages Friend/Family Other

Have you been under the care of a medical doctor during the past two years?
lf YES, for what?

Doctors Name:

Phone:

Address:

State:

Post Code:

Some medicines may interfere with your dentaltreatment or react with medicaments used by your dentist. It is important that your dentist knows precisely what medications that you are taking.

Are you taking any medication, drugs or pills now (or recently)?
 Yes No

Please include all medications, including aspirin, oral contraceptive, hormone replacement therapy, cortisone or steroids, warfirin, heparin or blood thinners, medication for depression, treatment for osteoporosis (biphosphonates), herbal or naturopathic medications and any over the counter medications.

lf YES, Please list name, dosage and frequency:

lf you are in any doubt about your medication, please bring the bottle, packet(s) or medication lists to the practice to show the dentist.

Are you aware of having an allergic (or adverse) reaction to any medication, substance or food?
 Yes No

lf YES, please list:

Have you ever been in hospital?
 Yes No

lf YES, please list:

Please indicate if you have ever had any of the following:
Rheumatic fever
 yes
Any heart (cardiac) complaint
 yes
A cardiac pacemaker
 yes
High or low blood pressure
 yes
Joint replacement surgery
 yes
Epilepsy (Convulsions)
 yes
Thyroid disease (including goitre)
 yes
Tuberculosis
 yes
Anti coagulant (blood thinning)
 yes
Blood disorders
 yes
Excessive bruising or bleeding
 yes
Osteoporosis or low bone density
 yes
Diabetes or family history of diabetes
 yes
Hepatitis, jaundice or liver disease
 yes
Neck, jaw or shoulder pain
 yes
Asthma / Bronchitis / Lung conditions
 yes
Any nervous system disorder
 yes
Gastric ulcer
 yes
Radiation therapy
 yes
Transplanted organ or bone marrow
 yes
Treatment for any form of cancer
 yes

Do you have or had any disease, condition or problem not listed?

lf YES, Please list :

Females are you:

Pregnant ?   yes

Breast feeding ?   yes

lf YES, when is your due date?

Date of:

Last dental visit:     

Last dental x-rays:  

 

Last dental clean:

How often do you brush your teeth?

How often do you floss?

Have you ever had any of the following?:
Does your jaw click or hurt?
 yes
Do you feel you grind your teeth?
 yes
Have you ever had orthodontic treatment?
 yes
Do you wear a night guard?
 yes
Have you ever had gum disease?
 yes
Have you ever had your bite adjusted?
 yes
Do you bite your cheeks often?
 yes
Do you smoke
 yes
Do you think you have occasional bad breath?
 yes
Do your gums ever bleed when you brush or floss your teeth?
 yes
Do you experience sensitivity in your teeth with hot or cold temperatures?
 yes
Does floss ever tear between your teeth?
 yes
Does food get jammed between your teeth?
 yes
Do your teeth ever hurt when you bite hard?
 yes

Other notes:

Declaration:

Please ask our receptionist for a copy of our privacy policy statement.
In signing this form I acknowledge that this represents an accurate medical history.
I will advise my dentist of any changes to my medical history in the future.
I understand that all medical details will be treated with professional confidentialily.
I understand that more than two working days notice is required upon CANCELLATION OR POSTPONEMENT a cancellation fee can be incurred..

We respect your privacy! Read more »