Adult Medical History Form

Adult Medical History Form

At Dental as Anything 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?*

Patient or FriendFacebookProfessionalFamilyPractice WebsiteTeam at DAASignageGoogleOther
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?*

ProactiveReactive
Patient Information
Title

MrMrsMsMissMaster
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:*
Home Phone:
Work Phone:
Your Preferred Phone:
Email*
Do you have Private Health Insurance?*

NoYes
Health Fund Name?*
Position (Line No) on the card?*
usually 1 or 2 digits
Do you have a DVA Card?*

NoYes
What is your DVA Membership No?*
0 to 10 digits
What is your DVA Card Type?*
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?*

ExcellentGoodFairPoor
Do you require antibiotic cover for dental treatment?*

NoYes
Please provide more details*
Do you currently smoke?*

NoYes
How many times per day?*
Have you ever smoked?*

NoYes
How long ago?*
Do you vape?*

NoYes
How many times per day?*
To ensure comprehensive care, how likely are you to doze off or fall asleep in the following situations described below. This is in contrast to just feeling tired.

(Epworth Sleepiness Scale)
1. Situation: Sitting and reading?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
2. Situation: Watching television?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
3. Situation: Sitting, inactive in a public place (ie. movies)?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
4. Situation: As a passenger in a car for an hour without a break?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
5. Situation: Lying down to rest in the afternoon?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
6. Situation: Sitting and talking to someone?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
7. Situation: Sitting quietly after lunch without alcohol?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
8. Situation: In a car, while stopping for a few minutes in traffic?*

0 - Would never doze1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing
Enter your total score to the 8 Situation questions:*
A score of 10 or greater indicates the possibility of a sleep breathing disorder.
Name of your Doctor (General Practitioner)
Doctor Phone:

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

	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?

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?*

NoYes
Are you allergic to anything? (eg: latex, penicillin, local anaesthetic, peanuts, etc.)*

NoYes
Please list what you are allergic to:*
Are you currently taking any medications? (including any natural remedies)*

NoYes
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?*

NoYes
Please describe for what?:*
Dental History
How long has it been since your last dental visit?*
Please tick any dental concerns you have below:

Bleeding GumsWorn, Broken TeethSounds from JointGrinding / Clenching TeethBad Appearance of TeethMissing TeethLoose TeethDifficulty ChewingBad BreathRapidly Decaying TeethUnsatisfactory DentureDiscoloured TeethDry MouthPain in Face or Jaw JointLost Filling / CavityToothacheSensitive Teeth
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":*

12345678910+10
Consent for Treatment & Communications*

I am happy to receive SMS and Email communication from Dental as Anything for critical or pertinent appointment reminders and any other information that pertains to dental awareness, health fund or governmental changes.I hereby consent to dental treatment deemed necessary by the dentists and agreed by my verbal consent beforehand to be carried out. I understand that it will be discussed with me before any staff takes x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.I agree to be responsible for the payment of all services rendered on my behalf and on behalf of my dependants. I understand that payments are due at the time of service.
Signature of Patient (or Guardian if patient is under 18 years old)*

Clear
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 described below. This is in contrast to just feeling tired.

Dental History