Medical History Form

Welcome To Our Practice!

Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.

Please Select  :  
Mr Mrs Ms Miss Master Dr 
Surname*:
First Name*:
Address:
 
Suburb:
Postcode:
Phone Home:
Work:
Mobile:
Date Of Birth:
Occupation:
Parent/Guardian names if under the age of 16:
Are you in a Private Health Fund for Dental?  Yes No 
If yes, which one?  
Are you covered by Veterans Affairs?  Yes No 
If yes, card number?  
How did you find out about Our Practice?  
Advertising Family & friends Internet Walk-in/Seen the sign Yellow Pages Other 
Have you ever had or do you have any of the following? (Please tick)
High Blood Pressure
Yes No 

Diabetes
Yes No 

Heart Conditions or Heart Surgery
Yes No 

Arthritis
Yes No 

Excessive Bleeding
Yes No 

Asthma or Bronchitis (Which one?)
Yes No 

Rheumatic Fever
Yes No 

HIV or Hepatitis A,B or C (Which one?)
Yes No 

Hip/Knee Replacement (Which one?)
Yes No 

Epilepsy
Yes No 

Anxiety or Depression (Which one?)
Yes No 

Hay Fever or Sinus
Yes No 

Allergies
Yes No 

Ladies, are you pregnant?
Yes No 

Radiation therapy to the head or neck
Yes No 

Treatment therapy for cancer
Yes No 


Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
Other serious injury or illness:
List any medication you are currently taking:
GP's Name and location:
Signature:
Date: