Medical and Dental History Form

1
Name* This field is required.
Given Name/s
Surname
Preferred Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Gender
Please Select
Please Select
Male
Female
Non-Binary
4
Address* This field is required.
Street Address
Street Address Line 2
Suburb
State
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Contact NumbersIf providing more than one number, please indicate your preferred contact number with the drop down box.
Mobile
Home
Work
Please Select
Please Select
Mobile
Home
Work
Best Contact Number
6
Email* This field is required.
example@example.com
7
DVA MembersIf you are a DVA recipient, please provide your card number and type. Consent is required for us to access your DVA file in order to apply for payment claims on your behalf.
DVA Number and Card Type
Please Select
Please Select
Yes - consent given
No - consent declined
Consent for us to access your DVA file for payment claims
8
Were you referred to this practice?
Please Select
Please Select
Yes
No
Referred by
Please Select
Please Select
Family or friend
Practice Website
Google
I am returning patient
If not referred, how did you hear about us?
9
Occupation
10
General Practitioner Information* This field is required.We ask for your GP's details to support coordinated care, as your oral health is closely connected to your overall health.
GP Name
GP Suburb
GP Phone
11
General Dentist Information* This field is required.This information helps us communicate with your general dentist and support continuity of care.
Dentist Name
Dentist Suburb
Dentist Phone
12
Emergency Contact InformationIn the event of a medical emergency.
Name
Please Select
Please Select
Spouse
Mother
Father
Sister
Brother
Partner
Other
Relationship
Contact Phone
13
Contacting YouWe prefer to speak with you directly about appointments, treatment or account matters. If we're unable to reach you, please let us know how you'd prefer us to leave a message.
Home answering machine
Email
Voicemail / SMS
At work
14
Authorised NomineeDo you authorise a Nominated Person to contact the Practice on your behalf in relation to your dental treatment appointment and financial matters?
Yes
No
15
Authorised NomineeContact Details
Name
Relationship
Contact Number
Email
16
Authorised NomineePermissions
Permission to enquire about treatment, medical and financial matters.
Permission to act on and make changes to treatment, medical and financial matters.
All of the above.
17
When was your last COMPLETE dental examination?
Date
Day
Month
Year
18
Are you in PAIN now?
YESNO
19
Are you in PAIN now?If you answered YES, please describe the pain and its location.
Huge
Large
Normal
Small
Ok
Ok
20
Have you ever had prolonged bleeding from a cut or tooth extraction?
YESNO
21
Have you experienced any problems or complications during or after dental treatment?
YESNO
22
Have you experienced any problems or complications during or after dental treatment?If you answered YES, please provide relevant details.
Huge
Large
Normal
Small
Ok
Ok
23
Have you had any problems with LOCAL ANAESTHETIC injections in the past?
YESNO
24
Do you have, or are you aware of, any of the following?Choose all that apply.
Uncomfortable bite
Problems chewing
Clicking jaw joints
Frequent headaches
Facial pain
Grinding or clenching
25
Do your gums bleed easily when brushing?
YESNO
26
Do you have your teeth cleaned regularly with a DENTAL PROFESSIONAL? When was your last clean?
27
Have you consulted a medical practitioner or been hospitalised in the past 12 months?
YESNO
28
Have you consulted a medical practitioner or been hospitalised in the past 12 months?If you answered YES, please provide details.
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Large
Normal
Small
Ok
Ok
29
Do you suffer from, or ever experienced, any of the following?Choose all that apply.
Asthma
Angina
Breathlessness
Diabetes Type I
Diabetes Type II
Epilepsy
Glaucoma
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Low Blood Pressure
Rheumatic Fever
Stroke
Thyroid Problems
30
Do you have any known allergies or sensitivities?
YESNO
31
Do you have any known allergies or sensitivities?If you answered YES, please provide details.
Huge
Large
Normal
Small
Ok
Ok
32
Please list ALL medications (including non-prescription) you are currently taking.Please include dosage, frequency and what the medication is use for.
Huge
Large
Normal
Small
Ok
Ok
33
Have you had any MAJOR operations?Including, but not limited to, joint / heart valve replacements, stents, etc.
YESNO
34
Have you had any major operations (i.e. joint / heart valve replacements, stents, etc.)?If you answered YES, please provide details, including surgery dates and contact information for overseeing surgeon.
Huge
Large
Normal
Small
Ok
Ok
35
Do you have any other serious illness not yet listed?Please provide a brief history.
Huge
Large
Normal
Small
Ok
Ok
36
Have you (or any family members) been diagnosed with or suspected of having Creutzfeldt-Jakob Disease or other illness affecting the brain or nervous system?
YESNO
37
Have you ever had surgery involving your spine or brain?
YESNO
38
Have you ever received a blood transfusion or blood products?
YESNO
39
Have you ever received a blood transfusion or blood products?If you answered YES, please advise when.
40
Have you ever received growth or fertility hormone?
YESNO
41
Have you possibly been exposed to AIDS and/or Hepatitis B and C viruses?
YESNO
42
Have you possibly been exposed to AIDS and/or Hepatitis B and C viruses?If you answered YES, please advise which virus.
43
Are you, or could you be, pregnant?
YESNO
44
Name of Person Completing the Form* This field is required.
First Name
Last Name
45
Date* This field is required.
Date
Day
Month
Year
Should be Empty: