*Surname
*First Name
*Date Of Birth
*Email
*Address
*Suburb
*Postcode
Preferred Contact Number Home PhoneBusiness / Work PhoneMobile Phone
Home Phone
Business / Work Phone
Mobile Phone
Employer
Occupation
Emergency Contact
Name
Relationship
Phone Number
Private Health Cover for Dental? YesNo
Health Fund Name
Person Responsible for Account
Who Referred You to Our Practice?
Confidential Medical History
Medical History Heart AilmentsAnginaAsthmaBlood DisorderDiabetes Type 1 or 2Neurological DisordersOsteoporosisStrokeKidney DiseaseEpilepsyCancerHIVHepatitis AHepatitis BHepatitis CCholesterolHigh Blood PressureLow Blood PressureMental HealthOther
Treated for Cancer? YesNo
Year of Treatment
Do You Smoke? YesNo
Cigarettes Per Day
Allergies & Medications
Drug Allergies? YesNo
Latex Allergy? YesNo
Other Allergies
Taking Medications? YesNo
List Medications
Receiving Medical Treatments? YesNo
List Treatments
Reaction to Local Anaesthetic? YesNo
Medical Practitioner Name
Medical Practitioner Phone
Possibly Pregnant? YesNo
Due Date
Last Dental Visit
Problems with Previous Visits? YesNo
Previous Experience
Grind Teeth? YesNo
Jaw Click? YesNo
Sore / Tired Jaw? YesNo
Prescribed Night Guard? YesNo
Brush Frequency Once A DayTwice A DayThree Times A Day
Toothbrush Type ManualElectric
Gums Bleed? YesNo
Flossing EverydaySometimesNever
Periodontal Disease? YesNo
Hygienist Treatment? YesNo
Worn / Uneven Edges? YesNo
Do These Bother You? YesNo
Chipped Teeth Bother You? YesNo
Spaces Bother You? YesNo
Like Tooth Colour? YesNo
How Would You Improve Your Smile? ColourAdd LengthAdd WidthShape
