Confidential Medical and Dental History Form

Please complete this form prior to your first dental appointment at Northern Dental Specialties

It is important to know details about your medical history as these could affect the success of oral health care (dental treatment). The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the second page of this form.

Please fill in the online form below or if you prefer, please download Word version of the form and  email the form to  reception@ndsmv.com.au

Word Version of Medical and Dental History Form

* Denotes required

Patient Information

Title:
First Name*:
Surname*:
Email*:
Date of Birth: / /
Home Address:
Postcode:
Home Phone:
Mobile:

Preferred form of contact:

Phone CallSMAEmailWork PhoneOther

if Other, please specify:

Do you belong to a Health Fund? YesNo

If yes, which one?

Business Contact

Your Occupation:
Work Phone:

Emergency Contact

Contact Name
Contact no:

Referral Information

How did you hear about our practice?

Dentist Please specify:
Patient Referral Please specify:
Internetstreet signadvertising

Confidential Health Information

Have you had any significant medical problems in the last year? YesNo
If yes, please specify

Do you have, or have you ever suffered from any of the following? Please select as appropriate:

Arthritis NOYES
Kidney Disease NOYES
Liver Disease/Hepatitis NOYES
Nervous Condition NOYES
Stroke NOYES
Diabetes NOYES
Epilepsy NOYES
Heart Condition NOYES
Bleed/Bruise Easily NOYES
High or Low Blood Pressure NOYES
Artificial Joints NOYES
Lung Disease/Asthma NOYES
Joint/ Valve Replacement NOYES
Blood/ Immune disorder NOYES
Snoring/Sleep Apnoea NOYES
Angina/Pace Maker NOYES
Osteoporosis/Bisphosphonates NOYES

Do you have any allergies? (E.g. penicillin, codeine, nickel, latex):

Have you ever taken Steroids NOYES
Have you ever takenBisphosphonates NOYES
Have you ever takenWarfarin NOYES
Have you ever had Jaw Joint Click/Lock NOYES
Have you ever had Headaches NOYES
Have you ever hadBad reaction Anaesthetic NOYES
Have you had any joint replacements NOYES
Do you smoke? NOYES
Are you pregnant? NOYES
Do you require antibiotic cover prior to dental treatment? NOYES

When did you last visit a doctor?

Who is your medical practitioner?

Please list ALL medications and or supplements.

Please describe the main reason for visiting our Practice?

I have read and accept the privacy statement following this form. I also understand Northern Dental Specialties require payment on the day of treatment.

Patient's acceptance:

Today's date:

 

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