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Patient Information
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Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Your Address
*
Email
*
Date of Birth
*
DD slash MM slash YYYY
Phone (Home)
Phone (Work)
Phone (Mobile)
Preferred Daytime Contact:
Home
Work
Mobile
Occupation
Employer
Emergency Contact
Relationship
Emergency Contact Phone Number
Name of person responsible for payment of accounts
Which Health Fund do you belong to?
Whom may we thank for recommending you to our practice?
Your Health
The state of your health may have a very significant effect on your dental care. Please answer these questions fully or discuss them with your dentist:
I have private and confidential medical matters which I wish to discuss with the dentist
Yes
No
Are you receiving any medical treatment at present?
Yes
No
Name of your medical practitioner / specialist
Have you ever been in hospital?
Yes
No
What was the nature of hospitalisation and dates:
Some medicines may interfere with your dental treatment or react with treatments used by your dentist. It is important that your dentist knows precisely what medications (if any) that you are taking. This should include:
If you are in any doubt about your medication, please bring the bottle or packet(s) to the practice to show the dentist.
Aspirin
Warfarin or heparin or other blood thinning medicine
Oral contraceptive
Hormone Replacement Therapy
Cortisone or steroids
Medication for depression (MAOls, SSRls, SNRls or Tricyclics)
Treatment for osteoporosis (bisphosphonates, Prolia)
Any other prescription medication
Any herbal or naturopathic medications
Any 'over the counter' medications
Please provide details (including dose and frequency) of any medicine or medication that you are currently taking, or have been taking recently.
Have EVER had any of the following health conditions? Is so please check the box to indicate which conditions you have experienced.
Rheumatic fever
Any heart (cardiac) complaint/treatment
Cardiac pacemaker
Heart valve replacement
High or low blood pressure
Anti-coagulant (blood thinning)
Blood disorders
Excessive bruising or bleeding
Osteoporosis or low bone density
Diabetes or family history of diabetes
Hepatitis, jaundice or liver disease
Urinary tract/Kidney disease
Joint replacement surgery
Jaw, neck or shoulder injury or pain
Epilepsy (Fits)
Thyroid disease (including goitre)
Tuberculosis (TB)
Asthma/Bronchitis/Lung conditions
Nervous system disorder
Anxiety/Depression
Gastroesophageal reflux disease (GORD)
Inflammatory bowel disease
Chemotherapy/Radiation therapy
Treatment for cancer (type/region)
Allergy or reaction to any medicine (including Penicillin or other antibiotic)
Allergy to any foods, chemical or substance (such as chlorine/latex/antiseptics/elastoplast)
Transplanted organ/bone marrow/stem cells
Snoring/Sleep Apnoea
Have you ever smoked?
Yes
No
Approximate date of quitting
Do you currently smoke?
Yes
No
For how long have you smoked and how much do you smoke per day?
Have you ever used illicit substances?
Yes
No
Have you ever required any treatment for smoking related diseases or conditions?
Yes
No
Do you suffer from any illness not listed above or carry any infectious disease?
Yes
No
If yes, please provide details
Are you Female?
Yes
No
Are you pregnant?
Yes
No
If yes, when are you due?
Are you breastfeeding?
Yes
No
DECLARATION
Do you acknowledge that the information provided accurately represents your medical history.
Yes
No
I will advise my dentist of any changes to my medical history in the future
Yes
No
I understand that all medical details will be treated with complete professional confidentiality
Yes
No
I have read and understand the privacy policy provided by this practice
View Our Privacy Policy
Yes
No
Patient Signature
*
(Parent or guardian if under 18 years) Typing your name below acts as a digital representation of your signature.
