Patient Medical Questionnaire

Patient Details:

Prefix

Other

Preferred Name

First Name

Family Name

Address

Suburb

Postcode

Date of Birth

Contact Details:

Phone (Home)

Phone (Work)

Phone (Mobile)

Preferred Daytime Contact

Occupation

Employer

Emergency Contact Details:

Emergency Contact Name

Relationship

Phone

Person responsible for payment of accounts

Which Health Fund do you belong to?

Who recommended you to our practice?

Please answer the following questions in regards to dental treatment:

Approximate date of your last dental visit

Purpose of that visit

What is the reason for your attendance today?

Do you have any dental concerns / fears when visiting the dentist?

What is the reason for leaving your last practice?

Are you sensitive to local anaesthetic?

Yes

Do you have a latex allergy?

Yes

The state of your health may have a very significant effect on your dental care. Please answer these questions fully or discuss them with your dentist:

I have private and confidential medical matters which I wish to discuss with the dentist

Yes

Are you receiving any medical treatment at present?

Yes

Name of your medical practitioner / specialist

Have you been admitted to hospital within the last 5 years?

Yes

If yes, nature of hospitalisation and dates:

Some medicines may interfere with your dental treatment or react with medicaments used by your dentist. It is important that your dentist knows precisely what medications (if any) that you are taking.

Please provide details (including dose and frequency) of any medicine or medication that you are currently taking, or have been taking recently.

Please choose medication and specify dosage if applicable.

Aspirin

Warfarin or Heparin or other blood thinning medicine

Oral contraceptive

Hormone Replacement Therapy

Cortisone or steroids

Medication for depression (MAOIs, SSRIs or Tricyclics)

Treatment for osteoporosis (Bisphosphonates, Prolia)

Aspirin dosage and frequency

Oral contraceptive dosage and frequency

Cortisone or steroids dosage and frequency

Warfarin or Heparin or other blood thinning medicine dosage and frequency

Osteoporosis (Bisphosphonates, Prolia) dosage and frequency

Hormone Replacement Therapy dosage and frequency

Medication for depression (MAOIs, SSRIs or Tricyclics) dosage and frequency

Any other prescription medication?

Yes

Please specify other prescription medication

Any herbal or naturopathic medications?

Yes

Please specify other herbal or naturopathic medications

Any ‘over the counter’ medications?

Yes

Please specify ‘over the counter’ medications

If you are in any doubt about your medication, please bring the bottle or packet(s) to the practice to show the dentist.

Please indicate YES or NO if you have ever had any of the following:

Treatment for cancer

Yes

If yes, please specify type/region.

Allergy or reaction to any medicine (including Penicillin or antibiotics)

Yes

If yes, please specify type of medicine.

Allergy to any foods, chemical or substance (such as chlorine/latex/antiseptics/elastoplast)

Yes

If yes, please specify type of food allergy.

Have you ever smoked?

Yes

Approx. date if Quitting?

Do you currently smoke?

Yes

If yes, for how long?

How much do you smoke per day?

Have you ever used illicit substances?

Yes

Have you ever required any treatment for smoking related diseases or conditions?

Yes

Do you suffer from any illness not listed above or carry any infectious disease?

Yes

If yes, please provide details

Declaration:

In signing this form I acknowledge that this represents an accurate medical history.

I will advise my dentist of any changes to my medical history in the future.

I understand that all medical details will be treated with complete professional confidentiality. I have read the privacy document provided by this practice.

I GIVE / DO NOT GIVE Absolute Dental permission to release information to the following third parties:

Signature

Sign Here

Patient Personal & Medical Questionnaire

Private & Confidential - The details you provide to us on this form are encrypted for your privacy.