Adult medical history

    Personal details

    Title *
    First name *
    Middle name *
    Last name *
    Sex *
    Date of birth *
    Home Address *
    Email *
    Mobile phone *
    Home phone *
    Employment Status *
    Are you covered by dental insurance? *
    Fund Name *

    Medical Information

    Family Doctor *
    Adress of Doctor *
    Patient's dentist *
    Date last seen by dentist *

    Patient's Medical and Dental History

    Please check if you ever had any of the following *
    What medications are you currently taking? *
    Are you pregnant? *
    Do you smoke? *
    Are there any other medical problems we should be aware of? *
    Pain or clicking in the jaw joints? *
    Chewing and swallowing difficulty? *
    Grind your teeth? *
    Have you teeth ever been injured due to an accident or having received a serious blow? *
    If yes, when?
    Why have you come to see us? *
    Other *

    Person responsible for paying accounts if not yourself. *

    Title
    First name *
    Surname *
    Address *
    Is responsible party Australian citizen? *

    Whom may we thank you for referring you. *

    My Dentist (Name and practice)
    Family / Friend (Name)
    School newsletter (Name)
    Newspaper advertisement (Name)
    Other

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