Medical/dental



Download 73.53 Kb.
Date conversion02.06.2016
Size73.53 Kb.




logo as an image.jpg
MEDICAL/DENTAL HISTORY FORM

It is important to know details about your medical history as these could affect the success of your dental treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy which is available upon request.

Title (eg Mr/Mrs/Ms): Last Name:
Date of birth: First name(s):
Home address: Postcode:

How did you find out about our practice?


Ph (hm): Ph (wk): Mob: Email:
Name of other family in attendance of our practice: Their Phone No:

I have confidential medical information that I do not wish to write down. I would prefer to speak to a dentist about this

(please tick box).



No Yes

List Medications:

Do you normally require antibiotic cover before dental treatment? Have you had any abnormal reactions to local or general anaesthesia? Do you smoke?

Are you pregnant? (Females only)

Are you being treated by a doctor at present?

Are you taking any prescription or other medications at present? Have you been hospitalised in the last 12 months?

Have you or anyone in your household returned from overseas travel in

the last 10 days?



















































Please list current medications:

Who is your medical practitioner: Medicare Number:

Please list any drugs or medicines you are allergic to:

Please list any other known allergies (including latex, foods and preservatives):

DO YOU HAVE NOW, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS?

Please tick either yes or no for each condition




No

Yes




No

Yes




No

Yes

Steroid therapy Rheumatic fever Epilepsy Asthma Diabetes Heart disorder/complaint

Bone disease, including osteoporosis

Radiation therapy








Kidney disease Excessive bleeding Stroke

Cancer


Thyroid disease

Snoring/ Sleep Apnoea


Anxiety/ Depression
High or low blood pressure







Prosthetic implant eg artificial hip Cardiac pacemaker Stomach or digestive condition Hepatitis or other liver diseases Contact with blood-borne viruses

Bronchitis, emphysema or other lung diseases

Anaemia, leukaemia or other blood diseases

Any other conditions







































































































































Any other condition(s) not mentioned (please list):

PLEASE LIST ANY CONCERNS OR PROBLEMS THAT YOU HAVE WITH YOUR TEETH OR MOUTH:

Do you belong to a health fund? Yes No If so, which one?



Your / Guardian’s signature: Date:

OFFICE USE ONLY Reviewed by: (please print name) Signature: Date:


The database is protected by copyright ©essaydocs.org 2016
send message

    Main page