Adult medical history

Personal details

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

Medical Information

Family Doctor *
Address of Doctor *
Suburb *
Postcode *
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? *
Do you have any allergies? *
If yes, what are the allergies?
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?
When did you have your last Dental Check - Up
Do you have any outstanding general dental work to be completed?
Why have you come to see us? *
Other

Person responsible for paying your accounts *

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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