Medical History Form

First Name:

Last Name:

Date of Birth:

Address:

Mobile

Home/Work Phone:

Email:

Occupation:

Referred by:

Dental Health Fund:

Are you receiving any medical treatment at this present time?

Yes No

Please list all your medications taken:

Have you experienced allergies or unusual effects from any tablets, injections or anaesthetic?

Yes No

Details:

Have you ever had any of the following?

Heart Problems

— Yes No

Blood Pressure

— Yes No

Artificial joints

— Yes No

Rheumatic fever

— Yes No

Circulatory problems

— Yes No

Radiation Treatment

— Yes No

Excessive Bleeding

— Yes No

Excessive Bruising

— Yes No

Ulcers (stomach)

— Yes No

Anemia or other blood disorders

— Yes No

Diabetes

— Yes No

Asthma

— Yes No

Hepatitis A,B,C,D,E

— Yes No

Epilepsy

— Yes No

Liver Problems

— Yes No

Kidney Problems

— Yes No

Sinus Trouble

— Yes No

Cancers/Tumours

— Yes No

WOMEN, are you pregnant? If so, when is your due date:

Name of your GP

Phone Number

Are you a smoker?

— Yes No

Name and location of last dentist? Approximate date of last dental visit?

Do you have dental pain or a dental problem at present?

Do you become anxious or uncomfortable when you are having dental treatment?

Yes No

Do you brush and floss daily?

Yes No

Do you grind or clench your teeth?

Yes No

Do you experience any sensitivity with hot/cold?

Yes No

Is there anything with your teeth that you are unhappy about?

Yes No

If Yes, details

How would you rate your smile on a scale of 1 to 10? (10 being perfect)

10 9 8 7 6 5 4 3 2 1

Is there anything else you would like the dentist to know?

Yes No

If Yes, details

I understand that if I fail to give 48 hours notice to cancel my appointment, that a fee may be charged. I agree to be responsible for payment of all services rendered on my behalf, and on the behalf of my dependents understand that this payment is due at the time of service unless other arrangements have been made.

Patient /responsible party’s name:

Relationship to patient: