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Medical History Online Form

Medical History form

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Medical History form

Complete Smile Dental New Patient / Medical History Form

Title

Mr. Mrs Miss Ms. Dr.

New patient Existing patient

First Name

Surname

Date of Birth

Address

Postcode

Suburb

Mobile

Home phone

Occupation

Private Health Fund

Yes No

Emergency Contact Name

Relationship

Emergency home/mobile phone no.

How did you hear about this practice

Internet Walk by Insurance Others Personal Referral

Do other family members attend this practice

Yes No

Please give full name(s)

How would you prefer to be contacted to confirm your appointments?

Phone Text Message Email

How would you prefer to be contacted to confirm your appointments?

Phone Text Message Email

HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING

HEART PROBLEMS

Yes No

ALLERGIES TO MEDICATIONS

Yes No

EXCESSIVE BRUISING

Yes No

ULCERS (stomach)

Yes No

EPILEPSY

Yes No

SINUS TROUBLE

Yes No

LIVER AND/OR KIDNEY PROBLEMS

Yes No

CANCER OR TUMOUR HISTORY

Yes No

RADIATION TREATMENT

Yes No

ASTHMA

Yes No

EXCESSIVE BLEEDING

Yes No

HIV, AIDS or HEPATITIS please circle if yes A B C

Yes No

ALLERGY TO PENICILLIN

Yes No

JOINT REPLACEMENTS (hip, knee, etc)

Yes No

ALLERGY TO LATEX

Yes No

RHEUMATIC FEVER

Yes No

ANAEMIA OR OTHER BLOOD DISORDERS

Yes No

CIRCULATORY PROBLEMS

Yes No

DIABETES please circle type 1 or 2

Yes No Type 1 Type 2

ALLERGIES TO ANAESTHETICSplease circle type 1 or 2

Yes No

BLOOD PRESSURE please circle HIGH or LOW

Yes No High Low

DO YOU SMOKE, If yes how many cigarettes a day?

Yes (If yes, please specify how many cigarettes a day? in message) No

FEMALES – ARE YOU PREGNANT

Yes No

ANY OTHER CONDITIONS

Yes No

Message

ARE YOU CURRENTLY TAKING ANY MEDICATIONS

Yes No

Medications

DO YOU/HAVE YOU TAKEN ANY DRUGS FOR CALCIUM AND BONE METABOLISM

Yes No

HOW LONG SINCE YOUR LAST DENTAL APPOINTMENT

HOW OFTEN DO YOU HAVE DENTAL EXAMINATIONS

WHEN DID YOU LAST HAVE DENTAL XRAYS TAKEN

CONSENT TO TREATMENT - I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetics, sedatives and other medications as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise that this data may be reviewed by team members of the dental practice.

GUARDIAN’S RELATIONSHIP TO PATIENT NAME:

NAME:

Our team, from top to bottom, including dentists, dental assistants and receptionists, are all highly trained, friendly & professional. The whole team comes together with only one goal

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(02) 6181 0997
info@optimsmile.com.au
Opening hours: 9:00am to 5:00pm Monday to Saturday
57 Ware St, Fairfield NSW 2165

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