New Patient Form DAP

NEW PATIENT FORM

Welcome to our practice. Please fill out this form to help us better serve you.
Name

First Name Last Name
Preferred Title

Mr Mrs Miss Ms Dr Prof
Gender

Male Female Other
Date of Birth

Day Month Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number

Area Code Phone Number
Mobile

Area Code Phone Number
Work Number

Area Code Phone Number
Email
example@example.com
Referred by

First Name Last Name
School (if student)
School year level
Ethnicity
NHI Number
Occupation
Medical History
Doctor/GP
Doctor/GP address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Doctor/GP phone number

Area Code Phone Number
Have you ever had any of the following?

Heart Murmur Irregular heart beat Rheumatic fever Heart Attack Open heart surgery Artificial heart valve Angina/Chest pain High blood pressure Cancer Radiotherapy for cancer treatment Chemotherapy for cancer treatment Stroke Neurological problems Arthritis Fainting Epilepsy Hay Fever Sinus Problems Asthma Reflux/Heartburn Chest/lung disease Diabetes Kidney problems Gastric problems Osteoporosis/Osteopenia Autoimmune disease Anxiety Depression Hyperthyroidism Hypothyroidism Genetic syndrome Organ transplant Blood disorders
If you had any of above please tell us when you were diagnosed, treatments received and the results of the treatment(s).
Do you have any other medical conditions/problems that were not listed above? If yes, please give us more information on it.
Are you taking any medicines, tablets, pills or drugs? If yes please list them.
Have you ever had any allergies to medicines or other substances (such as latex)? If yes, please list them.
Are you a smoker?

No Yes
How many years have you smoked?
How many a day?
Do you have an artificial prosthetic joint?

No Yes
If yes, please state when and what prothesis was placed:
Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time?

No Yes
Please explain what procedure was done and the kind of treatment you received.
Have you ever had contact with:

HIV virus Hepatitis B virus Hepatitis C virus
Please give us some more information on it.
Have you ever had an unfavorable reaction to a local anaesthetic

No Yes
Please give us more information on it.
Woman: Are you pregnant now or trying to get pregnant?

No Yes
Please let us know your due date, or if you don't know, how many weeks pregnant you are.
Are there any other medical/health matters you would like to discuss with your dentist?

No Yes
Please let us know what they are.
Emergency Contact

First Name Last Name
Phone Number

Area Code Phone Number
COVID SCREENING
Do you have a confirmed diagnosis of COVID-19?

No Yes
Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID-19?

No Yes
Have you, or anyone living with you returned from overseas in the last 14 days?

No Yes
Do you, or anyone living with you have the following symptoms (Please tick all symptoms that apply).

Sore throat Cough Shortness of breath High Temperature (38°C) Runny nose, sneezing, post-nasal drip
Oral Hygiene Habits
How many times a day you normally brush your teeth?

Not brushing daily Once a day Twice or more a day
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.

Not enough time It is painful Gums bleed when I do it Dont think it is important enough
What kind of toothbrush you use?

Manual brush Electric toothbrush
Is your toothbrush:

Soft Medium Hard Don't know
What kind of toothpaste do you use regularly?

With Fluoride Without Fluoride ("natural") For sensitive teeth Whitening Don't know
Do you floss or clean in between your teeth daily?

Yes No
Cleaning in between your teeth is fundamental for your a healthy and clean mouth. Please let us know why you are not flossing daily.

Too difficult It is painful Gums bleed when I do it Don't think it is important enough Not enough time for it
Dental Information
What are your main concerns regarding your mouth and dental care?
Could you please let us know what kinds of dental treatment you have received in the past? For example, braces, root canal treatment, fillings, cleans, extractions, crowns, etc.
Do you feel anxious when visiting the dentist?

No Yes
Please give us more information about it. For example, what is that you dislike and why.
Would you be interested in any form of sedation to help you through the treatment?

No Yes
Do you have any problems with your jaw joint? For example, noises, locks or pain.

No Yes
Please give us more information on it.
Are you interested in Botox or dermal fillers for concerns about wrinkles, expression lines, your lips or general appearance of your face?

No Yes
Please give us more information on it.
Are you happy with your smile and the colour/shape of your teeth?

No Yes
What would you like to change?
Are you concerned about the alignment/position of your teeth?

No Yes
Please give us more information on that.
Are you concerned about any missing teeth or gaps?

No Yes
Please give us more information on it.
Do your gums ever bleed or hurt?

No Yes
Please give us more information on it.
Have you ever noticed bad breath or are you concerned about it?

No Yes
Please give us more information on it.
Have you ever experienced gum recession?

No Yes
Please give us more information on it.
Have you ever been told that you have gum disease/periodontal disease?

No Yes
Please give us more information on it.
Are any of your teeth loose?

No Yes
Please give us more information on it.
Are any of your teeth sensitive or sore to hot, cold, sweets or biting on harder foods?

No Yes
Please give us more information on it.
Do you have any difficulty chewing food?

No Yes
Please give us more information on it.
Have you ever broken or chipped a tooth of filling?

No Yes
Please give us more information on it.
Do you get food caught in between your teeth?

No Yes
Please give us more information on it.
Have you noticed your teeth changing shape or getting shorter?

No Yes
Please give us more information on it.
Do you ever wake up in the morning with head or neck ache? Or pain on your teeth or jaws/face?

No Yes
Please give us more information on it.
Do you grind or clench your teeth?

No Yes
Please give us more information on it. Have you received any treatment for it? For example a night splint/guard.
Do you suffer from reflux or heartburn?

No Yes
Please give us more information on it.
Do you ever feel like your mouth is dry or have any issues with your saliva?

No Yes
Please give us more information on it.
Do you eat or drink very acidic foodstuff? Or used to? For example, lemons, vinegar, salad dressing, etc.

No Yes
Please give us more information on it.
Have you had significant trauma involving your face, head or neck?

No Yes
Please give us more information on it.
Sleep Medicine

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

Please answer these questions about the function of your nose:

Not a problem

Very mild problem

Moderate problem

Fairly bad problem

Severe problem

Nasal Stuffiness

Nasal blockage or obstruction

Trouble breathing through my nose

Trouble sleeping

Unable to get enough air through my nose during exercise or exertion

Calculation
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?

No Yes
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?

No Yes

Day time sleepiness scale - Tell us how likely you would be to doze off in these situations:

Would never doze

Slight chance of dozing

Moderate chance of dozing

High change of dozing

Sitting and reading

Watching TV

Sitting, inatice in a public place (e.g. theatre or in a meeting

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking with someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Calculation
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?

No Yes
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.
Is there anything else you would like us to know?
Emergency contact

First Name Last Name
Phone Number

Area Code Phone Number
I confirm that the information provided above is true and correct to the best of my knowledge.
Signature of Patient/Parent/Guardian

Clear
Date

Day Month Year
Date
Should be Empty:

NEW PATIENT FORM

Medical History

COVID SCREENING

Oral Hygiene Habits

Dental Information

Sleep Medicine