Medical History Form - Dental on George

Prefix

Mr/Mrs/Ms/Dr

Name

Surname First Name

Date of Birth

DD

MM

YYYY

Home Address

Street Address ZIP / Postal Code

Work Address

Street Address ZIP / Postal Code

Home Phone

Work Phone

Mobile Phone

Email*

Occupation

Drivers Licence Number (optional)

Private Health Fund

Reference on the card

Are you eligible for Child Dental Benefit Scheme

Yes
No

Medicare Number

Reference

Details of person to contact in an emergency

Name

First Last

Phone Number:

Medical Doctors Name

Phone (If known)

MEDICAL HISTORY

Are you receiving any medical treatment at present?

Yes
No

If yes, please provide details

Are you currently taking any medications?

Yes
No

If yes, please list all medications

Do you smoke?

Yes
No

If yes, how many a day, Please provide details

Are you, or have you been, under the care of a doctor during the past two years?

Yes
No

If yes, please state reason

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

Yes
No

If yes, please provide details

Have you ever had any of the following? If so, please tick as appropriate.

If Hepatitis - please Specify type A, B, C

Have you had any prosthetic surgery? (E.g. Heart Valve or Hip Replacement)

Yes
No

If yes, please give details

Ladies, are you pregnant or breastfeeding

Yes
No

If so, how many months

Are you HIV positive?

Yes
No

Are you at risk to HIV exposure?

Yes
No

DENTAL HISTORY

Have you ever had any of the following? If so, please tick as appropriate.

How long since your last dental appointment?

How often do you have dental examinations?

Would you like Dental on George to provide your future dental treatment?

Yes
No

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

Yes
No

Referred By:

Yellow Pages Online
Another patient/friend
Street Sign
Newspaper advertisement
Google search
Other

If Other, please specify

Please provide Name

Is another member of your family a patient at our practice:

Yes
No

Musical Preference:

Please state musical genre for your relaxation during treatment:

Signature

(Parents to sign if patient is under 18 years of age)

Today's Date

ON-LINE CONFIDENTIAL PATIENT QUESTIONNAIRE

Details of person to contact in an emergency

MEDICAL HISTORY

DENTAL HISTORY