Adult Medical History Form

Adult Medical History Form
Welcome to Dental as Anything, where we strive to provide you with the highest possible care.

To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this maintained in accordance with State and Federal Privacy Legislation.
How did you find us?
Who may we thank for referring you?
Please let us know how you did find us?
What did you type in to search for on Google?
When it comes to your oral health, which do you prefer to be?
Patient Information
Title
Given Name
Surname
Preferred Name
What do you prefer to be called
Date of Birth

DayMonthYear
DOB
Occupation
Residential Address

Street Address

Street Address Line 2

SuburbState

Postcode
Mobile Phone:
Format: 0000 000 000.
Home Phone:
Format: (00) 0000-0000 .
Work Phone:
Format: (00) 0000-0000.
Your Preferred Phone:
Format: 0000 000 000.
Email
Do you have Private Health Insurance?
Health Fund Name?
Position (Line No) on the card?
usually 1 or 2 digits
Do you have a DVA Card?
What is your DVA Membership No?
0 to 10 digits
What is your DVA Card Type?
Are you 18 or under and eligible for CDBS (Child Dental Benefits Scheme)?
Please enter your Medicare Card Number:
10 digit number
Please enter your Position No on your Medicare Card:
IRN - to the left of person's name
Next of Kin
In case of an emergency, whom would we contact?
Emergency Contact Name:
Relationship to Patient?:
(eg: mother, father, wife, husband, aunty, etc.)
Emergency Contact's Phone Number:
Medical History
How do you rate your general health?
Do you require antibiotic cover for dental treatment?
Please provide more details
Do you currently smoke?
How many times per day?
Have you ever smoked?
How long ago?
Do you vape?
How many times per day?
Name of your Doctor (General Practitioner)
Phone number for your Doctor (General Practitioner):

Have you had or are you suffering from any of the following?

Rows	Yes	No
Heart Trouble / Heart Surgery?
Tuberculosis?
Cardiac Pacemaker?
Arthritis?
Contact with Blood-borne viruses?
Thyroid Trouble?
Epilepsy?
Sleep Apnoea?
Stroke?
Steroid Therapy?
Bronchitis, Emphysema or Lung Condition?
Nervous Disorder?
Asthmatic?
HIV / AIDS?
Liver or Kidney Disease?
Rheumatic Fever?
Osteoporosis?
Anaemia, Leukaemia?
Eating Disorder?
Prosthetic Implant, Joint Replacement?
Stomach or Digestive Condition?
Excessive or Prolonged Bleeding?
Radiation or Chemotherapy?
(Females) Are you or could you be pregnant?

To ensure comprehensive care, how likely are you to doze off or fall asleep in the following situations. This is in contrast to just feeling tired.

(Epworth Sleepiness Scale)

Please enter a 0, 1, 2 or 3 for each question described below.

Rows	0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
1. Situation: Sitting and reading?
2. Situation: Watching television?
3. Situation: Sitting, inactive in a public place (ie. movies)?
4. Situation: As a passenger in a car for an hour without a break?
5. Situation: Lying down to rest in the afternoon?
6. Situation: Sitting and talking to someone?
7. Situation: Sitting quietly after lunch without alcohol?
8. Situation: In a car, while stopping for a few minutes in traffic?

Enter your total score to the 8 Situation questions: (add your 8 situation answers to get your total score).
A score of 10 or greater indicates the possibility of a sleep breathing disorder.
Do you have any other disease/condition(s) not listed above? Please enter details:
Blood Pressure?
Diabetes?
Hepatitis?
Have you ever had Botox or Facial Fillers?
Are you allergic to anything? (eg: latex, penicillin, local anaesthetic, peanuts, etc.)
Please list what you are allergic to:
Are you currently taking any medications? (including any natural remedies)
Please list what medications or natural remedies you are taking:
Additionally, you can upload a List of Medications or a Health Summary, dosages and frequency here:

Cancelof
Have you been hospitalised in the last 12 months?
Please describe for what?:
Dental History
How long has it been since your last dental visit?
Please tick any dental concerns you have below:
For Your Comfort

Whilst the improvement in techniques and anaesthetics have helped most people, you may still be apprehensive and wish us to take extra measures for your comfort. Please tick the number that indicates your present level of concern.
(1) being "Completely at Ease" and (10) being "Petrified":
Consent for Treatment & Communications
Signature of Patient (or Guardian if patient is under 18 years old)
Today's Date

DayMonthYear
Date signed
Should be Empty:

Adult Medical History Form

Patient Information

Next of Kin

Medical History

To ensure comprehensive care, how likely are you to doze off or fall asleep in the following situations. This is in contrast to just feeling tired.

Dental History