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  :  
    MrMrsMsMissMasterDr

    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?  YesNo

    If yes, which one?  

    Are you covered by Veterans Affairs?  YesNo

    If yes, card number?  

    How did you find out about Our Practice?  
    AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther

    Have you ever had or do you have any of the following? (Please tick)

    High Blood Pressure

    YesNo

    Diabetes

    YesNo

    Heart Conditions or Heart Surgery

    YesNo

    Arthritis

    YesNo

    Excessive Bleeding

    YesNo

    Asthma or Bronchitis (Which one?)

    YesNo

    Rheumatic Fever

    YesNo

    HIV or Hepatitis A,B or C (Which one?)

    YesNo

    Hip/Knee Replacement (Which one?)

    YesNo

    Epilepsy

    YesNo

    Anxiety or Depression (Which one?)

    YesNo

    Hay Fever or Sinus

    YesNo

    Allergies

    YesNo

    Ladies, are you pregnant?

    YesNo

    Radiation therapy to the head or neck

    YesNo

    Treatment therapy for cancer

    YesNo

    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:

    Contact Dentist Dee Why

    Our team is dedicated to providing personalized and compassionate dental care to our patients, and we’re
    always here to answer your questions or concerns.