Medical History
Full Name
*
First Name
Last Name
Title
Mrs
Mr
Dr
Ms.
Other
What is your Gender?
*
Male
Female
Date of birth
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Best contact option
Phone call
SMS Text
Email
Check the conditions that apply to you:
*
Asthma
Cancer
Cardiac disease
Hypertension
Psychiatric disorder
Epilepsy
Abnormal excessive bleeding
Angina
Artificial heart valve
Blood pressure (high)
Blood pressure (low)
Current or past bisphosphonate therapy
Cancer
Heart surgery/pacemaker
Congenital heart defect
Diabetes Type 1 or 2
Hearing impairment
Depressive illness
Heart murmur
Hepatitis A/B/C/D
HIV positive
Immune deficiency
Kidney disease
Liver disease
Neurological disorder
Prosthetic joints
Radiation/Chemotherapy
Steroid therapy
Smoking
Thyroid disorder
No medical concerns
Other
Are you taking any medications or over the counter medicines?
Do you have any allergies?
Penicillin
Latex
Food
Medication
Anaesthetic
Other
Do you smoke? How many per week?
Do you vape?
Are you pregnant? How many weeks?
Dental history
When was your last dental visit?
Is there a particular reason for your dental visit?
Have you ever had a bad reaction to dental treatment in the past?
Is there anything you would like your dentist or oral health therapist to be aware of?
Do you generally feel anxious about seeing your dentist or oral health therapist?
Yes - extremely
Yes - Very
Yes - somewhat
Not at all
Are you suffering from any of the following?
Bad appearance of your teeth
Bleeding gums
Bad breath
Difficulty chewing
Discoloured teeth
Dry mouth
Grinding/clenching
Missing teeth
Loose teeth
Lost filling/cavity
Pain in the face or jaw
Sensitive teeth
Tooth ache
Unsatisfactory denture
Worn or broken teeth
How did you find out about us?
Referral from a friend or family member
Google
Internet search
Work colleague
Other
If you were referred by someone, please let us know as we would like to show them our appreciation.
Name of referrer
I hereby authorise the dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependants.I understand that payment is due at the time of service unless arrangements have been made.
Yes
No
If you are under 18, please let us know the name and contact details of your parent/guardian.
Signature
Submit
Should be Empty: