Coastal Smiles

Welcome To Our Practice!

Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.

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?

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:

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.

ASK A QUESTION

MEDICAL HISTORY FORM

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