• NEW PATIENT FORM

    Welcome to our practice. Please fill out this form to help us better serve you.
  • Preferred Title
  • Gender
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  • Medical History

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  • Have you ever had any of the following?

  • Are you a smoker?
  • Do you have an artificial prosthetic joint?
  • Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time?
  • Have you ever had contact with:
  • Have you ever had an unfavorable reaction to a local anaesthetic
  • Woman: Are you pregnant now or trying to get pregnant?
  • Are there any other medical/health matters you would like to discuss with your dentist?
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  • COVID SCREENING

  • Do you have a confirmed diagnosis of COVID-19?
  • Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID-19?
  • Have you, or anyone living with you returned from overseas in the last 14 days?
  • Do you, or anyone living with you have the following symptoms (Please tick all symptoms that apply).

  • Oral Hygiene Habits

  • How many times a day you normally brush your teeth?
  • Brushing at least twice a day is fundamental for a healthy and clean mouth. Please tell us why you are not brushing your teeth at least twice a day.

  • What kind of toothbrush you use?
  • Is your toothbrush:
  • What kind of toothpaste do you use regularly?

  • Do you floss or clean in between your teeth daily?
  • Cleaning in between your teeth is fundamental for a healthy and clean mouth. Please let us know why you are not flossing daily.

  • Dental Information

  • Do you feel anxious when visiting the dentist?
  • Would you be interested in any form of sedation to help you through the treatment?
  • Do you have any problems with your jaw joint? For example, noises, locks or pain.
  • Are you interested in Botox or dermal fillers for concerns about wrinkles, expression lines, your lips or general appearance of your face?
  • Are you happy with your smile and the colour/shape of your teeth?
  • Are you concerned about the alignment/position of your teeth?
  • Are you concerned about any missing teeth or gaps?
  • Do your gums ever bleed or hurt?
  • Have you ever noticed bad breath or are you concerned about it?
  • Have you ever experienced gum recession?
  • Have you ever been told that you have gum disease/periodontal disease?
  • Are any of your teeth loose?
  • Are any of your teeth sensitive or sore to hot, cold, sweets or biting on harder foods?
  • Do you have any difficulty chewing food?
  • Have you ever broken or chipped a tooth of filling?
  • Do you get food caught in between your teeth?
  • Have you noticed your teeth changing shape or getting shorter?
  • Do you ever wake up in the morning with head or neck ache? Or pain on your teeth or jaws/face?
  • Do you grind or clench your teeth?
  • Do you suffer from reflux or heartburn?
  • Do you ever feel like your mouth is dry or have any issues with your saliva?
  • Do you eat or drink very acidic foodstuff? Or used to? For example, lemons, vinegar, salad dressing, etc.
  • Have you had significant trauma involving your face, head or neck?

  • Sleep Medicine

    You are almost there! We know it is a long form but this information is very important for us.
  • Rows

  • Understanding your score:

    0-25 is indicative of mild obstruction;

    25-50 is indicative of moderate obstruction;

    50-100 is indicative of severe obstruction;

    If you have any degree of nasal obstruction we recommend that you see your GP and an ENT for assessment. 

  • Have you been told that you snore?

  • Snoring is a sign of airway obstruction that can range from annoying and disturbing for your partner to life threatening sleep apnea. 

    Dont ignore the snore! 

    We can help you with that.

  • Have you been told that you hold your breath during sleep?
  • Rows

  • Understanding your score:

    0-10 is considered normal;

    11-14 is considered mild excessive sleepiness;

    15-17 is considered moderate excessive sleepines;

    18-24 is considered severe excessive sleepines;

    If you scored above 11 we recommend that you see a sleep medicine specialist 

    to diagnose and treat the cause of your sleepiness.

     

  • Are you happy with the quality of your sleep? Do you feel well rested and ready to tackle the day when you wake up?

  • Good quality sleep is fundamental for a healthy and enjoyable life, we really recommend that you seek help if you are not happy with the quality of your sleep.

    We can recommend and refer you on to a sleep specialist.

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  • I confirm that the information provided above is true and correct to the best of my knowledge.

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  • Should be Empty: