Medical History Questionnaire Your details Please select ---DrMrMstMrsMsMiss First Name Surname Phone Work phone Email Address Date of birth Occupation Employer Address Number Street Name Suburb Post Code Contact person in case of emergency Name Phone number Relation to you Health insurance Health insurance Ref No Member No Information Who referred you to our practice? When was your last dental visit? Why did you leave your last dentist? What has been your concern with previous dental visits What is your main dental concern today? Are your teeth sensitive to: HotColdBiting pressureSweet Does food catch between your teeth? Do your gums bleed when brushing or flossing? Do you notice an unpleasant taste or odour in your mouth? Have you had any complications during or following dental treatment? Have you had prolonged bleeding after tooth removal or dental surgery? Is there anything you would like to change about your teeth/gums or their appearance? Do you grind your teeth or clench your jaws? Have your jaw muscles ever been sore? Please describe how you feel about dental treatment (1 to 10) 12345678910 Do you smoke? YesNo How many per day? How long have you smoked? Are you being treated for a medical condition? Who are your doctors/GP / GP Clinic/ Specialist? Phone number: We may request access to medical history or medications for some dental treatments For Females Are you pregnant? YesNo What is your due date? Are you breast feeding? YesNo Are you taking Contraceptives? YesNo Name: Have you ever been hospitalized or had a major operation? YesNo When? Please give details Average alcohol intake per week? What is your current body weight (kg)? Do you take any of the following medications/supplements or treatments? Chemo / Radiation TherapyThyroxinHerbal / Natural MedsAsthma InhalersAnxiety MedicationsCholesterol MedsAnti-depressantsBisphosphatesBlood ThinnersBlood Thinners – Warfarin or AspirinProlia InjectionSteroid Tablets Please list all names of medications with dosage and frequency: I DECLARE I AM NOT TAKING ANY MEDICATIONS OR SUPPLAMENTS Do you have any allergies or sensitivity to any of the following and describe the reactions: AntibioticsLatexLactose / Milk productsBandagesCodeineVarious FoodsPenicillinSulphur Drugs OTHER- Please specify: I DECLARE I HAVE NO KNOWN ALLERGIES Are you taking any other medications or supplements at present, both prescribed or over the counter? (Please list with correct dosage & frequency) Do you have, or have you ever had, any of the following medical conditions? Steroid therapyRheumatic feverEpilepsyAsthmaDiabetesHeart valve disorderStrokeRadiation or chemotherapyKidney problemsHeart complaint or heart surgeryEating disorderStomach or digestive condition (reflux)Leukemia, cancersNervous conditionTuberculosisHeart murmurHigh blood pressureLow blood pressureOrgan or bone marrow transplantPacemakerBleeding problemsHepatitis or liver diseaseHIV/AIDSAnemia or blood disorderProsthetic implant eg. Prosthetic hip or kneeBronchitis, emphysema or otherLung diseaseOsteoporosisThyroid diseaseHypothyroidismHyperthyroidism Other I DECLARE I HAVE NO MEDICAL CONDITIONS We like to see you smile with confidence and get the most out of your visits. Please tick the dental care options you'd like to know more about or would consider in the future: Gum Therapy/ rejuvenation (PST)Tooth Coloured FillingsFresher BreathChildren's DentistryDry mouthCosmetic Tooth AlignmentTeeth WhiteningMissing teeth optionsOral Health Tips Dental Excellence from time to time offers in-house specials, gift vouchers, products, promotions and information seminars. Would you be interested in receiving an invitation? YesNo Would you prefer: SMSEMAILLETTER To protect your privacy do you give consent for a third party or family member access to your records? YesNo I give consent for: Full name of third party or family member: Contact details: Relationship: to: Update recordsMake changes to appointmentsRequest recordsMake enquirers on your behalf Please read and tick each section To the best of my knowledge, the questions above have been accurately answered. I understand the importance of providing both accurate and updated information to Dental Excellence. I understand 24 hours notice is required for cancellations or changes to my appointment, as fees may apply. I CONSENT the use of my dental diagnostic models, x-rays, before & after pictures for educational and/ or advertising purposes. No identity will be disclosed. I understand that major treatment requires a 20% deposit of the total cost to book a date and 50% of the major treatment cost may be requested 3-5days prior, or as advised by Dental Excellence. I am responsible for FULL PAYMENT of all my accounts UNLESS PRIOR APPROVAL obtained from the practice. Any collection fees incurred is my responsibility. I understand my responsibility to inform Dental Excellence of any changes to my medical status, health fund and contact details. I would like to be part of the Dental Excellence VIP club and receive a Facebook/ Twitter/ Instagram request. Patient Name: Date: Your name above is accepted as your electronic signature and declaration you have provided true and correct information.