Have you read our privacy policy?* Yes No Read Our Privacy PolicyDo you consent to its terms?* Yes No Personal InformationPatient Name* Mr.Mrs.MissMs.Dr. Title Preferred Name Patient Date of Birth* DD MM YYYY 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 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 DoctorMedical 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 am pregnant Other Health problems not listed Please provide details:If you are a smoker, how many per day?If you are pregnant, approximately how many months?7. I am or may be pregnantWomen only Yes No 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 problems 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*Dental Questionnaire10. 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. Do you attend regularly for check-ups, or do you usually only go to the dentist when something is wrong?13. Does dental treatment make you excessively anxious? Yes No 14. What do you regularly use for home care of your teeth?(eg brush, floss, mouthwash, etc)15. Do your gums bleed when you clean your teeth, while eating, or ever spontaneously bleed? Yes No 16. Do you have problems chewing/biting? Yes No 17. Does food commonly get caught between your teeth? Yes No 18. Are you unhappy with the appearance of your teeth? Yes No 19. Do you grind or clench your teeth, or have any jaw joint problems? Yes No (eg clicking/locking/limited movement/pain) 20. Do you experience frequent or regular headaches? Yes No 21. Do you wake up still feeling tired, despite being asleep for a reasonable time? Or do you suffer daytime drowsiness? Yes No (eg fall asleep readily and unexpectedly)22. Do you have a dry mouth? Yes No 23. Have you been disappointed with any previous dental treatment? Yes No If Yes, please provide details:24. Any other concerns?Oral Health HistoryMy major concern for today’s visit isWhen was the last time you received dental treatment? MM slash DD slash YYYY Have you had any trouble with any previous dental treatment?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 Are you dissatisfied in any way with the appearance of your teeth? Discolouration Crowding Spaces Gaps Crooked teeth Chipped teeth Other Please provide details: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!
