Medical History Form

Call us to make your appointment - we're looking forward to meeting you

Medical History Form

Call us to make your appointment - we're looking forward to meeting you

    Please complete the following confidential questionnaire, which will assist us in providing you with quality dental care. Alternatively the form could be downloaded here for you to complete and send to us.

    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
    Do you get headaches?
    YesNo
    Do you breathe through your mouth?
    YesNo
    Do you clench or grind your teeth?
    YesNo
    Do you snore?
    YesNo
    Do you feel refreshed in the morning when you wake up?
    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:
    Redcliffe Dental