Medical History Form - Choice Dental

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Medical History Form2025-06-25T20:34:46+00:00

CONFIDENTIAL MEDICAL HISTORY FORM

Dear valued patient,
Welcome to our practice. The following information is requested to enable us to give you our best attention. Each question is related to modern dental procedures and is strictly confidential.
Title*
- Mr.
- Mrs.
- Ms
- Miss
- Master
- Dr
Surname*
First Name*
Date of birth*
DD slash MM slash YYYY
Address*
Suburb*
Post Code*
Home Telephone
Business Telephone
Mobile*
E-mail Address*
Occupation*
Emergency contact Name*
Relationship*
Emergency Home/Mobile*
How did you hear about this practice?
- Internet website/Google
- Personal Referral
- Walk by
- Health Fund
- Yellow Pages Online
- Facebook
- Newspaper
- Drewvale GP Pamphlet
- School Newsletter
- Other
Personal Referral(who may we thank)*
(Other)please specify*
Do you have PRIVATE HEALTH INSURANCE?
- YES
- NO
Health fund name
Name of your medical practitioner (GP) or the Medical Centre you attend
Please answer the following Questions regarding medical conditions and Health history:
Please give details if you answer yes to the following
Do you normally require Antibiotic cover before dental treatment?*
- Yes
- No
Reason?
Any ALLERGIES?*
- Yes
- No
Allergies
Please list any medications you are currently taking*
If none, please write "none"
Have you had any problems with previous dental treatment?*
- Yes
- No
write more info
Anemia*
- Yes
- No
Anemia Details
Artificial Joints*
- Yes
- No
Artificial Joints
Asthma*
- Yes
- No
Asthma details
Blood Pressure*
- Yes
- No
Blood Pressure Details*
- Low Blood Pressure
- High Blood Pressure
Blood Thinning Meds*
- Yes
- No
Blood Thinning Details
Cancer / medication*
- Yes
- No
Cancer Details
Contact with HIV/AIDS*
- Yes
- No
Contact with HIV/AIDS Details
Depression*
- Yes
- No
Depression Details
Diabetes: (Type)*
- Yes
- No
Diabetes Details
Epilepsy*
- Yes
- No
Epilepsy Details
Heart Problems*
- Yes
- No
Heart Problem
Hepatitis: A B C D E*
- Yes
- No
Hepatitis Details
Liver or Kidney Problems*
- Yes
- No
Liver/Kidney Details*
Osteoporosis/bone disease*
- Yes
- No
Osteoporosis/bone details
Pacemaker/artificial valve*
- Yes
- No
Pacemaker Details
Pregnancy*
- Yes
- No
(details if YES) Due Date
Radiation Treatment*
- Yes
- No
Radiation treatment details
Reflux*
- Yes
- No
Reflux Details
Rheumatic Fever*
- Yes
- No
Rheumatic Fever Detials
Sinus Trouble*
- Yes
- No
Sinus Details
SMOKER/VAPER*
- Yes
- No
Smoker Details
Stroke*
- Yes
- No
Stroke Details
Thyroid Disease*
- Yes
- No
Thyroid Details
Ulcers (stomach)*
- Yes
- No
Ulcer Details
Any other Conditions*
- Yes
- No
Other Conditions Details
Patient Declaration:
• I have completed this form to the best of my knowledge and acknowledge that this represents an accurate medical history. On future visits I will advise the Dentist of any changes to this history.
• I agree to be responsible for payment of all services rendered on my behalf and on the behalf of my dependents.
• I understand and agree that payment is due and will be made at the time of my appointment
Consent*
If I am unable to attend future appointments, I will give 48 hours notice to this surgery. Otherwise I’m aware an administration fee will be incurred.*
Signed*
Date*
DD slash MM slash YYYY
(Parent/Guardian if under 18 years). Print Name

Δ

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