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* Date Format: 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? Personal Referral Walk by Health Fund Yellow Pages Online Internet website/Google Other Personal Referral(who may we thank)*(Other)please specify*Do you have PRIVATE HEALTH INSURANCE? YES NO Health fund nameName of your medical practitioner (GP) or the Medical Centre you attendPlease 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 AllergiesPlease 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 infoAnemia*YesNoAnemia DetailsArtificial Joints*YesNoArtificial JointsAsthma*YesNoAsthma detailsBlood Pressure*YesNoBlood Pressure Details* Low Blood Pressure High Blood Pressure Blood Thinning Meds*YesNoBlood Thinning DetailsCancer / medication*YesNoCancer DetailsContact with HIV/AIDS*YesNoContact with HIV/AIDS DetailsDepression*YesNoDepression DetailsDiabetes: (Type)*YesNoDiabetes DetailsEpilepsy*YesNoEpilepsy DetailsHeart Problems*YesNoHeart ProblemHepatitis: A B C D E*YesNoHepatitis DetailsLiver or Kidney Problems*YesNoLiver/Kidney Details*Osteoporosis/bone disease*YesNoOsteoporosis/bone detailsPacemaker/artificial valve*YesNoPacemaker DetailsPregnancy*YesNo(details if YES) Due DateRadiation Treatment*YesNoRadiation treatment detailsReflux*YesNoReflux DetailsRheumatic Fever*YesNoRheumatic Fever DetialsSinus Trouble*YesNoSinus DetailsSMOKER*YesNoSmoker DetailsStroke*YesNoStroke DetailsThyroid Disease*YesNoThyroid DetailsUlcers (stomach)*YesNoUlcer DetailsAny other Conditions*YesNoOther 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 Date Format: DD slash MM slash YYYY (Parent/Guardian if under 18 years). Print Name
