Medical History Form

Personal Details

Title

Emergency Contact Name

Emergency Contact Name Phone Number

Person Responsible For Payment

Private Health Insurance Details

Are Any Other Members Of Your Family A Patient At Our Surgery?

Have You Had Any Of The Following:

Are You Currently Taking Any Drugs/Medications?

Yes No

Are you currently taking any blood thinners like Clopidogrel, Warfarin, Pradaxa?

Yes No

Have you ever been prescribed or currently taking any bisphosphonate medication like Fosamax, Alendronate, Risedronate, Pamidronate, Zoledronic, Ibandronate, Clodronate, Tiludronate, Denosumab, Etidronate?

Yes No

Does your jaw “click” or hurt?

Yes No

Do you feel that you grind or clench your teeth?

Yes No

Have you ever had orthodontic treatment?

Yes No

Do you wear a dental night guard?

Yes No

Have you ever had periodontal (gum) treatment?

Yes No

Have you ever had your bite adjusted?

Yes No

Do you bite your lips or cheeks often?

Yes No

Do you smoke?

Yes No

Do you think you have occasional bad breath?

Yes No

Do you experience sensitivity with hot/cold?

Yes No

Do your gums ever bleed when you clean your teeth?

Yes No

Do your teeth ever hurt when you bite hard?

Yes No

Does floss ever tear between your teeth?

Yes No

Does food ever get jammed in between your teeth?

Yes No

Is there anything else you would like us to know?

Other Information

Name of your General Practitioner

Phone number of your General Practitioner

Ladies, are you pregnant?

Yes No

If ‘yes’, when is the due date?

How long since your last dental appointment?

How often do you have dental examinations?

Were previous dental x-rays taken less than one year ago?

Yes No

Consent for Treatment

I hereby authorise the dentist or designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis

Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed to by me and to employ such assistance as required to provide proper care

I agree to the use of anaesthetics’, sedatives and other medication as necessary. I fully understand that using anaesthetics agents embodies certain risks. I understand I can ask for complete recital of any possible complications.

I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

I authorise that this data may be reviewed by team members of the dental practice.

Acceptance

I agree & authorise

Canberra Dental Care

Medical History Form

Personal Details

Medical History

Other Information

Canberra Dentists In Belconnen

CALL US

MAKE AN APPOINTMENT