CONFIDENTIAL
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Title (Mr, Mrs, Dr etc)
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Surname*
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Given Names*
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Preferred Name
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Date of Birth*:
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Home Address:
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Suburb*:
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Post Code*:
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Mail Address (if different to home address)
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Address
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Suburb
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Post Code*:
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| Please note we require at least two contact telephone numbers |
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Home Phone*:
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Work Phone*:
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Mobile:
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Fax No:
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Email*:
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Your preferred contact method: (Please tick applicable)
Email SMS Mobile Home Phone Work Phone |
Occupation:
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Employer:
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Do you have dental health insurance?
Yes No |
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If so, Fund Name:
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Card #:
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Are you covered by Veteran Affairs?:
Yes No |
File Number:
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How did you hear about us?
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| Do any other members of your family come to this practice? |
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Member 1
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Member 2
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Member 3
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Contact In Case Of Emergency
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Name:
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Phone:
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| 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
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Family Doctors’ Name:
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Phone:
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Is your general health?:
Excellent Good Fair poor
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When was your last medical check up?
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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 |
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Any other Medication?
Yes No |
If yes, please list: |
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| Do You Have Or Have You Ever Had: |
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Heart problems:
Yes No
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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:
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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 |
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Anything else we should know about your medical history?
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List of current medications:
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DENTAL HISTORY
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| 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? |
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| Please answer YES or NO to the following questions: |
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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 |
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