PATIENT PERSONAL & MEDICAL QUESTIONNAIRE
PRIVATE & CONFIDENTIAL
Welcome to Smileworx
This information is necessary for orthodontic patients to provide us with a background for understanding your overall health and to evaluate orthodontic related concerns. Please answer the following questions as completely as possible.
Title
Please Select
Mr.
Mrs.
Ms.
Mx.
Dr.
Prof.
Other
Email
*
example@example.com
Name
*
First Name
Last Name
Preferred Name
First Name
Last Name
DOB
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
*
Male
Female
Non binary
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Phone Number (Home)
-
Area Code
Phone Number
Phone Number (Mobile)
Please enter a valid phone number.
Format: 0000-000-000.
Name of any sibling(s) currently attending the practice:
*
If no siblings attend, please write 'None'
DENTAL HISTORY
Referred to us by:
Dentist
Self-Referred
Other
Please enter other referral type below
General Dentist Name
Practice Name
Date of Last Dental Appt:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
PLEASE INDICATE BELOW IF YOU HAVE SUFFERED ANY OF THE FOLLOWING:
Heart Condition/Disease
Asthma
Tonsils Removed
Rhematic Fever
Cleft Lip/Palate
Adenoids Removed
Kidney or Liver Probems
Jaw Pain/Locking
Grinding/Clenching
Diabetes
Speech/Hearing Problems
Thumb Sucking
Hepatitis
Mental Health Issues
Snoring/Sleep Apnoea
Bleeding Problems
History of Eating Disorder
Mouth Breathing
Epilepsy
Anxiety/Depression
Nail/Lip Biting
Arthritis
Sensory Issues
Commenced Puberty
Commenced Puberty
Trauma/Damage to Teeth
Do you suffer from an illness/condition not listed above? (If yes, please provide further details below):-
Are you allergic to any drugs, medicines, or latex?
Yes
No
Do you have any other known allergies?
Is there a possibility that you could be pregnant?
Yes
No
Do you have any private and/or confidential medical matters you wish to discuss with the Orthodontist?
Yes
No
Parent/Guardian Information
Parent/Guardian Name 1 (if applicable):
Full Name
Contact Number
Parent/Guardian Name 2 (if applicable):
Full Name
Contact Number
Billing Party Information
Use same details as above in 'Patient Information'?
Yes
No
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By ticking this box, I acknowledge that I have read and understood the Terms & Conditions and give my consent for Smileworx Orthodontics to collect, store, and use my personal information for the purpose of managing my treatment and associated payment arrangements
*
Yes
No
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Should be Empty: