Choice Dental 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 TelephoneBusiness TelephoneMobile* 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 followingDo 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 DetailsLiver 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 DetailsPatient 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
