New Patient Form

CONFIDENTIAL

Title (Mr, Mrs, Dr etc)
Surname*
Given Names*
Preferred Name
Date of Birth*:
Home Address:
Suburb*:
Post Code*:

Mail Address (if different to home address)

Address
Suburb
Post Code*:
Please note we require at least two contact telephone numbers
Home Phone*:
Work Phone*:
Mobile:
Fax No:
Email*:
Your preferred contact method: (Please tick applicable)
 Email SMS Mobile Home Phone Work Phone
Occupation:
Employer:
Do you have dental health insurance?
 Yes No
If so, Fund Name:
Card #:
Are you covered by Veteran Affairs?:
 Yes No
File Number:
How did you hear about us?
Do any other members of your family come to this practice?

Member 1

Member 2

Member 3

Contact In Case Of Emergency

Name:
Phone:
Once you book an appointment, we will consider this a confirmed appointment and will attempt one courtesy reminder. We value your time so please value ours. Please note that a fee will be charged for a failure to attend or a late cancellation – less than 48 hours notice.

Medical History

Family Doctors’ Name:
Phone:

Is your general health?:
 Excellent Good Fair poor

When was your last medical check up?
Are you allergic to any of the following? (Please tick applicable)
 Penicillin Erythromycin Tetracylcine Codiene Local Anaesthetic Fluoride Metals (Gold/Stainless Steel) Asprin Ibuprofen Acetaminaphen Latex/Rubber
Any other Medication?
 Yes No
If yes, please list:
Do You Have Or Have You Ever Had:

Heart problems:
 Yes No

Rheumatic/Scarlet fever:
 Yes No
High blood pressure:
 Yes No
Low blood pressure:
 Yes No
Prolonged Bleeding:
 Yes No
Artificial prosthesis:
 Yes No
Anemia/Blood disorder:
 Yes No
Emphysema:
 Yes No
Tuberculosis:
 Yes No
Stroke:
 Yes No
Asthma:
 Yes No
Sleep disorder:
 Yes No
Kidney disease:
 Yes No
Jaundice:
 Yes No
Thyroid/Parathyroid:
 Yes No
Hormone deficiency:
 Yes No
Ulcer/Stomach disorder:
 Yes No
Diabetes:
 Yes No
High cholesterol:
 Yes No
Gastric reflux:
 Yes No
Osteoporosis/osteopenia:
 Yes No
Arthritis:
 Yes No
Glaucoma:
 Yes No
Contact lenses:
 Yes No
Head/Neck injury:
 Yes No
Epilepsy/Convulsions:
 Yes No
Neurologic problems:
 Yes No
Viral infections:
 Yes No
Cold sores:
 Yes No
Severe headaches:
 Yes No
Lumps/Swelling in the mouth:
 Yes No
Hives/Hay fever/Skin rash:
 Yes No
Hepatitis:
 Yes No
Hepatitis Type:
HIV/AIDS:
 Yes No
Venereal disease:
 Yes No
Tumor, abnormal growth:
 Yes No
Radiation therapy:
 Yes No
Chemotherapy:
 Yes No
Psychiatric treatment:
 Yes No
Depression:
 Yes No
Alcohol/drug dependency:
 Yes No
Weight management:
 Yes No
Smoker/Smoked previously:
 Yes No
Female – on birth control?:
 Yes No
Female – are you pregnant?:
 Yes No
Male – prostate disorders?:
 Yes No
Anything else we should know about your medical history?
List of current medications:

DENTAL HISTORY

Previous Dentist: Last check up:
When did you last have dental x-rays?: Last Treatment (other than a cleaning):
How often do you see a dentist? What are your immediate concerns?
Please answer YES or NO to the following questions:
Are you fearful of dental treatment?
 Yes No
Have you had an unfavourable dental experience?
 Yes No
Have you had complications after dental treatment?
 Yes No
Do you have difficulty with dental anaesthetic?
 Yes No
Have you had orthodontic treatment?
 Yes No
Have you had oral surgery?
 Yes No
Is there anything about your teeth you would like to change?
 Yes No
Have you whitened (bleached) your teeth?
 Yes No
Have you been disappointed with previous dental work?
 Yes No
Are you self-conscious about your teeth?
 Yes No
Are your teeth crowding or developing spaces?
 Yes No
Do you have problems chewing gum/bagels/hard food?
 Yes No
Has your dental appearance changed in the last 5 years?
 Yes No
Do you have pain/limited opening/locking or popping jaw problems?
 Yes No
Do you suffer tension headaches or sore teeth?
 Yes No
Do you grind your teeth?
 Yes No
Do you/or have you worn a bite appliance?
 Yes No
Have you had any cavities in the last three years?
 Yes No
Do you have a dry mouth?
 Yes No
Are you teeth sensitive to hot/cold/sweet foods?
 Yes No
Have you had tooth ache/cracked fillings/cracked/chipped teeth?
 Yes No
Do you avoid brushing some areas of your mouth?
 Yes No
Do you notice holes or pitting in your teeth?
 Yes No
Have you ever been diagnosed with periodontal/gum disease?
 Yes No
Have you ever experienced gum recession?
 Yes No
Is there a history of periodontal disease in your family?
 Yes No
Do your gums bleed when eating/flossing or brushing?
 Yes No
Are your teeth becoming loose?
 Yes No
Do you notice an unpleasant taste of odour in your mouth?
 Yes No
Have you ever experienced a burning sensation in your mouth?
 Yes No
Please Enter Anti-Spam Code Below
captcha

APPOINTMENTS : (03) 9824 7722 - 1007 Malvern Road, Toorak Melbourne VIC 3142

Our Company

General Dentist

Cosmetic Dentist

Corrective Procedures

Contacting Paltoglou Dental

1007 Malvern Road
Toorak, Melbourne 3142
APPOINTMENTS 03 9824 7722

 

Join our newsletter for updates
& special offers.