www.rhdp.com.au - MEDICAL HISTORY FORM

MEDICAL HISTORY FORM
Name*

TitleFirst NameSurname
Date of Birth*

MonthDayYear
Has your medical history changed since filling in your last medical update, including medications?

YesNo
If no, please scroll to the bottom and sign
If yes, please complete the form
Residential Address

Street Address

Street Address Line 2

SuburbPostcode

Postcode
Email Address*
example@example.com
Contact Number
Emergency Contact Name*
Emergency Contact Number*
Doctor's Name
Doctor's Clinic Number
Medicare Card Number
Medicare reference number (number next to your name on card)
Private health fund name for dental insurance
Private Health Membership Number
Private Health Reference number (number next to your name on card)
Are you eligible for the Child Dental Benefits Schedule (CDBS)?*

YesNo
Medicare Card Number
Reference number (number next to your name on card)
Name of person responsible for fees if not self
Parent/guardian name (if applicable)
Carer name (if applicable):
MEDICAL HISTORY DETAILS

Do you suffer from any of the following allergies or health problems?
Please tick each relevant box
Are you allergic to penicillin*

YesNo
Are you allergic to local anaesthetic*

YesNo
Are you allergic to latex*

YesNo
Are you allergic to any medications*

YesNo
If yes please state which*
Heart Problems*

YesNo
Prosthetic Implant*

YesNo
Respiratory Issues*

YesNo
High Blood Pressure*

YesNo
Low Blood Pressure*

YesNo
Diabetes*

YesNo
If yes what type?*
Lung Disease*

YesNo
Neurological (Nerve) Problems*

YesNo
Cancer*

YesNo
If yes where?*
Rheumatic Fever*

YesNo
Tuberculosis*

YesNo
Anemia or other blood problems*

YesNo
Stroke*

YesNo
Arthritis*

YesNo
Pacemaker*

YesNo
Sinus Trouble*

YesNo
Any Artificial Joint*

YesNo
Please state if yes*
Epilepsy / Seizures*

YesNo
Back or Neck Problems*

YesNo
Osteoporosis*

YesNo
Asthma*

YesNo
Liver or Kidney Problems*

YesNo
AIDS or HIV*

YesNo
If yes what type?*
Circulatory Problems*

YesNo
Thyroid Problem*

YesNo
Excessive Bleeding*

YesNo
Hepatitis?*

YesNo
If yes what type?*
Please list any other relevant medical history
Please list any other allergies
Please state any major surgery you have had in the last five years
Are you Pregnant?*

YesNo
If yes, how many weeks?*
Is there anything you would like to discuss in private?
Do you feel anxious about your dental appointment?
MEDICATIONS
There are many medications that may impact your oral health or the treatment we plan for you.
Please indicate any medications that you are currently taking or have taken recently (including natural therapies). Alternatively a list from your GP can be provided separately ( Please note below if this will be separately provided)
Are you on any blood thinners such as Warfarin or Aspirin?*

YesNo
Consent to Treatment
I hereby authorise the applicable clinician or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the applicable clinician to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorise the applicable clinician to perform all recommended treatments mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetics agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
Your Privacy
Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed. The policy of our practice is to follow these procedures: The information collected will beused for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of adding accounts to you, as well as processing payments and writing to you about our services and any issues affecting your treatment. We may disclose your health information to other health professionals, or require it from them if, in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible. We may also use parts of your health information for research purpose, in study groups or seminars as this may provide benefit to other patients. Should this happen, your personal identity will not be disclosed without your consent to do so. Your medical history, treatment records, x-rays or any other material relevant to your treatment will be kept at the practice. You are welcome to inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees may apply in relation to the types of access you seek. If you request an explanation of our records or a written summary, our standard fees may apply to these services. If any information we have about you is inaccurate, you may ask us to alter our records accordingly. You can otherwise rest assured your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of the practice, without your prior written consent. If you have any queries or concerns about the handling of your health information, please do not hesitate to raise these concerns with our practice. Otherwise, please sign this form as confirmation that you have read and understood our privacy policy, and consent to the use of your health information in this way.
Patient / Parent or guardian signature*

Clear
Patient / Parent or guardian name*

First NameLast Name
Date*

MonthDayYear
Date
135 Shoreham Road | info@rhdp.com.au | rhdp.com.au | 5989 2144
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MEDICAL HISTORY FORM

MEDICAL HISTORY DETAILS

Please tick each relevant box

MEDICATIONS

Consent to Treatment

Your Privacy