Medical History Form

First Name:

Last Name:

Date of Birth:

Address:

Mobile

Home/Work Phone:

Email:

Occupation:

Referred by:

Dental Health Fund:

Are you receiving any medical treatment at this present time?

Yes No

Please list all your medications taken:

Have you experienced allergies or unusual effects from any tablets, injections or anaesthetic?

Yes No

Details:

Have you ever had any of the following?

Heart Problems

—YesNo

Blood Pressure

—YesNo

Artificial joints

—YesNo

Rheumatic fever

—YesNo

Circulatory problems

—YesNo

Radiation Treatment

—YesNo

Excessive Bleeding

—YesNo

Excessive Bruising

—YesNo

Ulcers (stomach)

—YesNo

Anemia or other blood disorders

—YesNo

Diabetes

—YesNo

Asthma

—YesNo

Hepatitis A,B,C,D,E

—YesNo

Epilepsy

—YesNo

Liver Problems

—YesNo

Kidney Problems

—YesNo

Sinus Trouble

—YesNo

Cancers/Tumours

—YesNo

WOMEN, are you pregnant? If so, when is your due date:

Name of your GP

Phone Number

Are you a smoker?

—YesNo

Name and location of last dentist? Approximate date of last dental visit?

Do you have dental pain or a dental problem at present?

Do you become anxious or uncomfortable when you are having dental treatment?

Yes No

Do you brush and floss daily?

Yes No

Do you grind or clench your teeth?

Yes No

Do you experience any sensitivity with hot/cold?

Yes No

Is there anything with your teeth that you are unhappy about?

Yes No

If Yes, details

How would you rate your smile on a scale of 1 to 10? (10 being perfect)

10987654321

Is there anything else you would like the dentist to know?

Yes No

If Yes, details

I understand that if I fail to give 48 hours notice to cancel my appointment, that a fee may be charged. I agree to be responsible for payment of all services rendered on my behalf, and on the behalf of my dependents understand that this payment is due at the time of service unless other arrangements have been made.

Patient /responsible party’s name:

Relationship to patient: