Medical History Questionnaire Download PDF "*" indicates required fields 1Consent2Your Details3Health Insurance4History5Females6Medications & Declarations WE RESPECT YOUR PRIVACY*In order to provide you with the highest standard of dental care, this practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number, but it is also necessary for us to obtain from you details regarding your general health and past medical or surgical treatments and procedures. Without this general health profile, the treating Dentist or Hygienist is unable to plan your care properly. Naturally, some of this information is of a personal nature, some of it may be regarded as 'sensitive' and not the sort of information you would wish to be unnecessarily disclosed to others. Our practice is equipped with CCTV security cameras always visible and in discreet areas such as the waiting room, treatment rooms and the sterilisation area. Our monitored system is installed to keep the safety of our patients and staff in check when and if required. You can rest assured that our system records and saves video footage only for a few days and records it over itself again. This assists us in ensuring safe delivery of treatment services are being carried out at all times as well as for our staff's safety and peace of mind. If you are concerned in any way, please don't hesitate to contact us. We value the need to safeguard this information and in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that: • This information will only be used by the treating Dentist or Hygienist in order to deliver your care to the highest standards. • It will not be disclosed to those not associated with your treatment without your expressed consent. • You may seek access to the information held about you and we provide this access within 2-3 days of a written request received. This access might be by inspection of your dental records at the time of your appointment or by special access or copying of information at other times by completing a records release request form. • We will not send clinical information about patients via email unless it is to secure domain email addresses and not gmail, yahoo, hotmail or other free emails. • We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date. • We will take all reasonable steps to protect the privacy of our patients’ information from misuse or loss and from unauthorised access, modification or disclosure. • Our staff are trained to respect these principles at all times. If you have any questions regarding the information we collect from you and hold in your dental records, please do not hesitate to ask us. We are acting in your interest at all times. I agree to the privacy policy. Your DetailsHave you been to our Practice before?* Yes, I'm an existing patient No, Im a New Patient Name* Dr.Mr.Mrs.MissMs.Mx. Prefix First Last Address* Street Address Suburb Postcode Phone*Work PhoneEmail* Date of Birth* Day Month Year OccupationEmergency ContactEmergency contact*Relation to you*Phone*To protect your privacy do you give consent for a third party or family member access to your records? Yes No If yes, please provide details below.Full name of third party or family memberRelationshipContact details Health InsuranceHealth InsurerRef. No.Member No. HistoryWho 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: Hot Cold Biting pressure Sweet Does food catch between your teeth? Yes No Sometimes Do your gums bleed when brushing or flossing? Yes No Sometimes Do you notice an unpleasant taste or odour in your mouth? Yes No Sometimes Have you had any complications during or after dental treatment? Yes No Details if YesHave you had prolonged bleeding after tooth removal or dental surgery? Yes No Is there anything you would like to change about your teeth/gums or their appearance?Do you grind your teeth or clench your jaws?* Yes No Sometimes Do you suffer from: Sore jaw muscles Headaches / Migraines Neck / Backpain Do you feel sleepy or tired during the day? No Yes Sometimes (during some activities)Do you SNORE LOUDLY No Yes (enough to be heard through closed doors)?Please describe how you feel about dental treatment (1: Pleasant to 10:Terrible) 1 2 3 4 5 6 7 8 9 10 Do you smoke? No Cigarettes Vape Other If Yes, how many/often per dayHave you recently quit smoking? Yes If Yes, how long ago?If Yes, how many/often per day?What is your current body weight (kg)?Average alcohol units consumed per week Questions specific to females* Answer Skip Section FemalesAre you pregnant? No Yes 1st Trimester 2nd Trimester 3rd Trimester If Yes, when is your due date?Are you breast feeding? No Yes Are you taking contraceptives? No Yes If Yes, please name contraceptive Medications & DeclarationsAre you being treated for a medical condition? Yes No Details if YesWho are your doctors/GP/GP Clinic/Specialist?We may request access to medical history or medications for some dental treatments.PhoneHave you ever been hospitalized or had a major operation? Yes No Details if YesDo you take any of the following medications, supplements or treatments? Chemo / Radiation Therapy Thyroxin Herbal / Natural Meds Asthma Inhalers Anxiety Medications Cholesterol Meds Anti-depressants Bisphosphates Blood Thinners Blood Thinners – Warfarin or Aspirin Prolia Injection Steroid Tablets Please list names of all medications or supplements including those not listed above with dosage and frequency:I DECLARE I AM NOT TAKING ANY MEDICATIONS OR SUPPLEMENTS I DECLARE I AM NOT TAKING ANY MEDICATIONS OR SUPPLEMENTS Do you have any allergies or sensitivity to any of the following? Antibiotics Latex Lactose / Milk products Bandages Codeine Various Foods Penicillin Sulphur Drugs Please list all allergies including those not listed above and describe the reactions:I DECLARE I HAVE NO KNOWN ALLERGIES I DECLARE I HAVE NO KNOWN ALLERGIES Do you have, or have you ever had, any of the following medical conditions? Steroid therapy Rheumatic fever Epilepsy Asthma Diabetes Type 1 Diabetes Type 2 Diabetes Gestational Heart valve disorder Stroke Radiation or chemotherapy Kidney problems Heart complaint or heart surgery Eating disorder Stomach or digestive condition (reflux) Leukemia, cancers Nervous condition Tuberculosis Heart murmur High blood pressure Low blood pressure Organ or bone marrow transplant Pacemaker Bleeding problems Hepatitis or liver disease HIV/AIDS Anemia or blood disorder Prosthetic implant eg. Prosthetic hip or knee Bronchitis, emphysema or other Lung disease Osteoporosis Thyroid disease Hypothyroidism Hyperthyroidism OtherI DECLARE I HAVE NO MEDICAL CONDITIONS I DECLARE I HAVE NO MEDICAL CONDITIONS This field is hidden when viewing the formWe 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 Fillings Fresher Breath Children's Dentistry Dry Mouth Cosmetic Tooth Alignment Teeth Whitening Missing Teeth Options Oral 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 information? Yes No Would you like to receive special offers via SMS Email This field is hidden when viewing the formPlease 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 AgreePlease read and tick each section*I understand 24 hours notice is required for cancellations or changes to my appointment, as fees may apply. I Agree*Please read and tick each sectionI 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 ConsentPlease read and tick each section*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 Agree*Please read and tick each section*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 Agree*Name*Date* Day Month Year Your name above is accepted as your electronic signature and declaration you have provided true and correct information.LinkedInThis field is for validation purposes and should be left unchanged.
