New patient form Your details Preferred contact phone: Home phoneBusiness phoneMobile phone Do you have Private Health Cover for Dental: YesNo Confidential Medical History Are you or have you ever been treated for any of the following? Rheumatic FeverDiabetes Type 1/2Blood DisorderHIV/Hepatitis A B CKidney disease AsthmaNervous DisordersEpilepsyMalariaAngina A strokeHigh/Low Blood PressureHigh/Low CholesterolCancer - enter year: Do you smoke? YesNo If yes, how many per day? 5102030 Do you have any drug allergies? YesNo Latex allergy? YesNo Are you currently taking any medications? YesNo Are you currently receiving any medical treatment? YesNo Have you had an unfavourable reaction to local anaesthetics? YesNo Ladies, is there a possibility that you are pregnant? YesNo Have you had problems with previous dental visits? YesNo Do you feel that you grind your teeth? YesNo Does your jaw click? YesNo Do you wake with a sore/tired jaw? YesNo Have you ever been prescribed a “night guard”? YesNo How often do you brush your teeth? Once a dayTwice a dayThree times a day Which type of toothbrush do you use? ManualElectric Do your gums bleed when you clean your teeth? YesNo Do you floss? Every daySometimesNever Have you ever been diagnosed with Periodontal Disease? YesNo Have you ever had your gums treated by a Dental Hygienist? YesNo Do you have worn, uneven edges on your teeth? YesNo If yes, do these bother you ? YesNo Do you have chips on your teeth that bother you? YesNo Do you have spaces that bother you? YesNo Do you like the colour of your teeth? YesNo How would you improve your smile? ColourAdd lengthAdd widthShape We request and expect payment at the time of treatment. For your convenience Design Dental Group is equipped with the "HICAPS" system and accept cash, cheques, eftpos, and most major credit cards.
