Medical / Dental History Form
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2Medical / Dental History Form
It is important to know about your medical history as these could affect your dental treatment and how we can provide this treatment
safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on
the reverse of this form.
: ____________________________________________________
: ____/____/____
Name
Date of Birth
________________________________________________________________________
Home & Postal Address:
): ____________________
): ________________
: _______________________
Ph (home
Ph (work
Mob
:
Email
Occupation: _______________________________________
How would you like to be contacted for appointment reminders?
SMS
Email
Phone call
None
How would you like to receive your 6 Monthly Check-up reminders?
SMS
Email
Letter
None
Name of emergency contact person: _________________________________________ Their Ph: __________________________
Who is your medical practitioner? ____________________________________________ __ Phone: _________________________
I have confidential medical information that I do not wish to write down. I would prefer to speak to a dentist about this.
How did you hear about us?
Internet
Phone book
Newspaper
Patient (their name) ________________________
Are you in a Private Health Fund with Dental cover? If so, which one: __________________________________________________
Yes
No
List Medications
Are you taking any prescription or herbal medication or supplements?
____________________________
Do you normally require antibiotic cover before dental treatment?
____________________________
Have you had any abnormal reactions to local or general anaesthesia?
____________________________
Do you smoke?
____________________________
Are you or could you be pregnant? (Females only)
____________________________
Are you being treated by a doctor at present?
____________________________
Have you been hospitalised in the last 12 months?
____________________________
Have you or anyone in your household returned from overseas
travel in the last 10 days?
____________________________
____________________________
Please list all known ALLERGIES (including drugs, latex, foods & preservatives): _________________________________________
_________
_________________________________________________________________________________________________________
Do you have now, or have you ever had, any of the following medical conditions? (Please tick any you have or had)
Asthma
High blood pressure
Stroke
Tuberculosis
Low blood pressure
Diabetes
Bronchitis, emphysema or other lung diseases
Heart disorder/complaint
Epilepsy
Thyroid disease
Cardiac pacemaker
Cancer
Hepatitis or other liver diseases
Rheumatic fever
Steroid therapy
Excessive bleeding
Stomach or digestive condition
Radiation therapy
Anaemia, leukaemia or other blood diseases
Nervous or psychiatric condition
Kidney disease
Contact with blood-borne viruses
Prosthetic implant e.g. artificial hip /knee
Bone disease, including osteoporosis
Any other condition (please list) ________________________________________________________________________________
I have read and accept the ‘PRIVACY POLICY’ on the reverse of this form.
Signature: _____________________________________________________________ Date: ______________________________
(Parent/Guardian needs to sign if patient is under 18 years)
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