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.
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?*
ProactiveReactive
Patient Information
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:*
Format: 0000 000 000.
Home Phone:
Format: (00) 0000-0000 .
Work Phone:
Format: (00) 0000-0000.
Your Preferred Phone:
Format: 0000 000 000.
Email*
NoYes
Health Fund Name?*
Position (Line No) on the card?*
usually 1 or 2 digits
NoYes
What is your DVA Membership No?*
0 to 10 digits
What is your DVA Card Type?*
No - I am older than 18Yes - I am 18 or under and eligible for CDBSYes - I am 18 or under, but unsure if eligible for CDBS
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
ExcellentGoodFairPoor
NoYes
Please provide more details*
NoYes
How many times per day?*
NoYes
How long ago?*
NoYes
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?*
NoYes
NoYes
Please list what you are allergic to:*
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
NoYes
Please describe for what?:*
Dental History
How long has it been since your last dental visit?*
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.
12345678910+10
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)*
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