02 9971 8992
Suite 1, 5 Dee Why Parade, Dee Why
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Dr Peter Sayegh
Dr Reza Nikfar
Dr Bez Shokouhi
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APPOINTMENT INFORMATION
Medical History Form
Welcome To Our Practice!
Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.
Please Select
:
Mr
Mrs
Ms
Miss
Master
Dr
Surname*
:
First Name*
:
Address
:
Suburb
:
Postcode
:
Phone Home
:
Work
:
Mobile
:
Date Of Birth
:
Occupation
:
Parent/Guardian names if under the age of 16
:
Are you in a Private Health Fund for Dental?
Yes
No
If yes, which one?
Are you covered by Veterans Affairs?
Yes
No
If yes, card number?
How did you find out about Our Practice?
Advertising
Family & friends
Internet
Walk-in/Seen the sign
Yellow Pages
Other
Have you ever had or do you have any of the following? (Please tick)
High Blood Pressure
Yes
No
Diabetes
Yes
No
Heart Conditions or Heart Surgery
Yes
No
Arthritis
Yes
No
Excessive Bleeding
Yes
No
Asthma or Bronchitis (Which one?)
Yes
No
Rheumatic Fever
Yes
No
HIV or Hepatitis A,B or C (Which one?)
Yes
No
Hip/Knee Replacement (Which one?)
Yes
No
Epilepsy
Yes
No
Anxiety or Depression (Which one?)
Yes
No
Hay Fever or Sinus
Yes
No
Allergies
Yes
No
Ladies, are you pregnant?
Yes
No
Radiation therapy to the head or neck
Yes
No
Treatment therapy for cancer
Yes
No
Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
Other serious injury or illness:
List any medication you are currently taking:
GP's Name and location:
Signature
:
Date
:
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MEDICAL HISTORY FORM
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