Patient Medical History Form

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CONFIDENTIAL MEDICAL & DENTAL HISTORY FORM
Personal Details
It is important to know details
about your medical history, as
Last Name: ______________________ First Name/s: _______________________
these could affect the success
Title: ______ Preferred Name: _____________________ D.O.B.: ___/____/____
of your dental treatment. The
Home Address: ___________________________________ __________________
information you provide is
Suburb: ___________________________ State: ________ Post Code: _________
confidential and will be
handled in accordance with
Home : ________________________Mobile : __________________________
our privacy policy
Email : ___________________________________________________________
Occupation: ___________________ Work: _________________ Private Health Fund: _______________________
Emergency Contact:___________________ Relationship:________________ Phone:__________________________
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How did you hear about us?
Yellow Pages
Website
Health Fund
Car Sign
Street Sign
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Patient/Friend - Name_______________________________________________
Dental History
(For New Patients Only)
Name of last dentist: ______________________________________ Date last attended: _______________________
Do you have any current concerns: __________________________________________________________________
Medical History Details
Name of your medical practitioner: __________________________________ Phone: _________________________
Please answer the following questions to the best of your ability
Yes
NO
Details / List
Are you being treated by a doctor at present?
Are you currently taking any tablets or medication (prescribed or
over the counter)?
Do you normally require antibiotic cover before dental treatment?
Do you have abnormal reactions to local or general anaesthesia?
Do you smoke?
Daily Quantity:
Are you pregnant? (females only)
No. Of weeks:
Do you have an allergies (including medication, Latex)?
DO YOU HAVE, OR HAVE EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS? :
YES NO
YES NO
YES NO
Rheumatic Fever
Kidney Disease
Prosthetic Joint
Epilepsy
Excessive Bleeding
Cardiac Pacemaker
Asthma
Heart Complaint
Stomach or Digestive
Diabetes (Type 1or 2)
Nervous Condition
Hepatitis (A, B or C)
Heart Valve Disorder
Tuberculosis
Liver Disease
Stroke
Thyroid Disease
Contact with HIV/AIDS
Transplanted Organ or
Leukaemia/ Other Blood
Bronchitis/Emphysema
Marrow
Disease
Steroid Therapy
Low Blood Pressure
Anaemia
Radiation Therapy
High Blood Pressure
Mental Illness
Any other conditions/Surgery:
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