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
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?
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:
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
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
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 »