Personal InformationPatient Name* Mr.Mrs.MissMs.Dr. Title Preferred Name Patient Date of Birth* Day Month Year Home Address* Street Address City State Postcode Home Address* Street Address City State Postcode Provide your phone number* Home Phone Mobile Phone Work Phone Home Phone*Mobile Phone*Work Phone*Email* Emergency ContactEmergency Contact Name*Relationship To YouEmergency Contact Email Emergency Contact Phone*Are you in a health fund for dental? If yes, please add which fund and Patient ID No e.g. 01 Yes No Which Fund?Patient ID NumberDo you have a voucher for Medicare “Child Dental Benefits Scheme”? If yes, please add your id no. on the card. Yes No Id NumberAre you covered by Veterans Affairs (Repat)? Yes No Person Responsible For FeesHow did you come to our practice? Personal referral (friend/family member/work colleague) On-line/search (Google/search engine, Facebook, link etc) Saw surgery/signage as passing Name of Personal referralPlease provide details(Google/search engine, Facebook, link etc)Medical HistoryMust be completed in fullWho is your medical doctor / specialist?1. Are you presently under the care of a medical doctor? Yes No If yes, what condition is being treated?2. Please list any medications, tablets or drugs you are currently taking or have taken in the past year? Yes No If yes, what medicines are you taking?3. Have you ever had any allergic reaction to any medication? Yes No If yes, please provide details:4. Have you experienced prolonged bleeding? Yes No If Yes, please provide details:5. Have you had any adverse reaction to dental treatment? Yes No If Yes, please provide details:6. Please tick any of the following which you have had: Rheumatic fever Heart murmur Congenital heart disease Heart trouble Heart attack Stroke Pacemaker Prosthetic or artificial heart valve Heart surgery High blood pressure Low blood pressure Blood disease Known bleeder Taking a blood thinner Hepatitis HIV Blood Transfusion Asthma Respiratory problems Tuberculosis Diabetes Thyroid problems Arthritis Allergy Hypersensitivity Epilepsy Fits Cancer Chemotherapy Radiation therapy Bone disorders Bone medications (Bisphosphonates) Prosthetic or Artificial joint(s) Stomach problems Kidney disease Anxiety Depression I am a Smoker I use a Vape Other Health problems not listed Please provide details:If you are a smoker, how many per day?If you use a Vape, how many per day?7. I am or may be pregnant Yes No If you are pregnant, approximately how many months?Approximate date of confinement, if known: DD slash MM slash YYYY 8. Is there anything confidential you would prefer to discuss with the dentist in private? Yes No 9. Have you been hospitalised or had any serious health problem including surgery during the past year? Yes No If yes, what was the problem?Please tick* I confirm that the above is my/my child’s information and medical history, I am responsible for payment, and give my consent for dental treatment. Name of Child (if applicable)Dental Questionnaire / Oral Health History10. What is the main reason for your dental attendance?*(eg check-up, toothache, sensitive tooth/teeth, broken tooth, bleeding gums, pain, swelling, discoloured tooth etc)11. When was your last dental visit?12. Does dental treatment make you excessively anxious? Yes No 13. Are you unhappy with the appearance of your teeth? Yes No 14. Do you experience frequent or regular headaches? Yes No 15. Do you have a dry mouth? Yes No 16. Any other concerns?Do you experience any of the following? Toothache Swelling on your gum around a tooth Sensitivity to Hot Cold Sweets Biting pressure Bleeding gums Concern with your breath Loosening teeth Drifting teeth Missing teeth Denture problems Broken tooth Lost filling Decay (cavity) Grinding Clenching Worn teeth Jaw joint clicking Jaw joint pain Food catching between your teeth Privacy Policy & TermsHave you read our privacy policy?* Yes No Read Our Privacy PolicyDo you consent to its terms?* Yes No Infection Control AssuranceOur practice enforces “UNIVERSAL PRECAUTIONS”. All instruments and handpieces used in our surgery are sterilised by autoclaving for every patient. This ensures maximum protection and safety for everyone!
