Patient History

Title—Please choose an option—MrMrsMiss

First Name*

Last Name*

Preferred Name

Gender—Please choose an option—MaleFemaleOtherNot prefer to say

Date of Birth*

Street Address*

Suburb*

State*

Postcode*

Home Phone

Work Phone

Mobile*

Email*

Preferred Method of Contact—Please choose an option—PhoneEmailSMS

Emergency Contact Person*

Relationship*

Emergency Contact Phone*

Medical Doctor (GP)

Practice Name

Private Health Fund

DVA Card Number

Have you been treated for a medical condition, or been admitted to hospital in the last 2 years? YN

Do you have, or have you had any of the following medical conditions?

A multi-drug resistant infection (e.g. golden staph-MRSA or VRE) YN High or low blood pressure YN Heart disease/disorders (e.g. atrial fibrillation, rheumatic fever, congenital disorders, heart attack) YN Treatment for any form of cancer (e.g. surgery, radiotherapy, immunotherapy) YN An organ transplant (e.g. kidney, liver, heart, lung, bone marrow) YN Heart surgery (e.g. valve replacement, stent, bypass, or pacemaker/implantable cardiac device ICD) YN Neurological disorders (e.g. epilepsy, motor neurone disease, Parkinson's, stroke) YN Blood thinning medications (e.g. warfarin, aspirin, apixaban, dabigatran, rivaroxaban, clopidogrel, heparin) YN Intellectual/cognitive or physical disability requiring assistance (e.g. dementia, wheelchair, guide/therapy dog) YN Lung disease (e.g. asthma, COPD/emphysema, cystic fibrosis, pneumonia) YN

Mental health issues (e.g. anxiety, depression, bipolar) YN Diabetes (e.g. type I or II) YN Are you a current or past smoker? Do you use vapes? YN Kidney disease (e.g. dialysis) YN Blood borne viruses or liver disease (e.g. hepatitis B or C, HIV) YN Sleep apnoea YN Do you have any disease, condition or problem not listed (e.g. autoimmune disorders)? YN Bone disease (e.g. osteoporosis) including bone altering medications (oral or infusions) YN Joint replacement surgery (e.g. knee, hip) YN Are you pregnant? YN

Please provide a list of medications you are currently taking including over the counter or natural medicines

Do you have any allergies (e.g. antibiotics, latex)? YN

I have completed this questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place ME at undue medical risk. I understand that notes, radiographs (X-rays), or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this.

Clear

Date

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