Online Patient Medical History Form

Patient Information
Surname:* (Mr/Mrs/Miss/Dr):
First Name:* Date of Birth:*
Address:*
Suburb:* Postcode:* Home Phone:*
Mobile Number: Work Phone:
Email: Occupation:
Person Responsible For Fees (If Not Self):
Emergency Contact: Phone Number:
Is another member of your family a patient at our practice?: Family Member First Name and Surname:
How would you like us to remind you of your appointment?:
Medical History

Have You Had Any Of The Following? (Tick If Yes)

Type (A,B,C,D,E):

Do you have or have you had any diseases, conditions or problems not listed here Please List:

Women

Are You Pregnant? Are You Taking Oral Contraceptive Pills?

Do you have allergies or reactions to:

Please List:
Are you currently taking any drugs or medicines? If So Please List:
Name of your Physician: Phone Number:
Address:
Dental History
What is the reason for your visit today?:
Date Of Last Dental Examination (Or Nearest Estimation): Date Of Last X-Rays (Or Nearest Estimation):
Date Of Last Dental Cleaning (Or Nearest Estimation):
How Often Do You Have Dental Examinations: If Other, Please Specify:
How often do you brush your teeth?: How Often Do You Floss?:
What other aids do you use? (e.g Electric Toothbrush, Manual Toothbrush, Toothpicks, Interdental Brushes):
Have you had any of the following?
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.