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Medical History

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Medical History

Please fill out our medical history form so we can get to know your teeth.

Name*
Title First Last
Date of Birth
DD slash MM slash YYYY
Parent / Guardian's Names
If under the Age of 16
Phone
Occupation
Address
Address Line 1 Address Line 2 Suburb State Postcode
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?
Have You Ever Had or Do You Have Any of the Following?
- High Blood Pressure
- Diabetes
- Heart Conditions or Heart Surgery
- Arthritis
- Excessive Bleeding
- Asthma
- Bronchitis
- Rheumatic Fever
- HIV
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Hip Replacement
- Knee Replacement
- Epilepsy
- Anxiety
- Depression
- Hay Fever or Sinus
- Allergies
- Ladies, Are You Pregnant?
- Radiation Therapy To The Head Or Neck
- Treatment Therapy for Cancer
Diseases of Bone/ Other Cancer That Has Spread to the Bone
E.g. 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*
DD slash MM slash YYYY
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Swansea Dental Practice is dedicated to maintaining and improving your dental health.
Swansea Dental Practice is conveniently located in central Swansea and has plenty of free parking. We are close to bus links, and our surgery is wheelchair accessible.

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Contact Us

Swansea Dental Practice
43 Josephson St
Swansea NSW 2281
(02) 4971 1432
admin@swanseadental.com.au Email Swansea Dental
Monday to Friday
8.00am – 6.00pm

© 2020 Swansea Dental Practice. All Rights reserved.