Child medical history

Personal details

First name *
Middle name *
Last name *
Sex *
Date of birth *
Home Address *
Suburb *
Postcode *
Parent Email *
Parent Mobile phone *
Parent phone 2 *
Relation to Patient *
Title *
First name *
Surname *

Person responsible for paying accounts

Title *
First name *
Surname *
Occupation *
Employment Status *
Billing Address *
Suburb *
Postcode *
Is responsible party Australian citizen? *
Is patient 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 patient ever had any of the following *
What medications patient is currently taking *
Is the patient pregnant? *
Does patient smoke? *
Do you have any allergies? *
If yes, what are the allergies?
Are there any other medical problems we should be aware of? *

Does the Patient *

have Pain or clicking in the jaw joints? *
have Chewing and swallowing difficulty? *
Grind their teeth? *
have a speech problem? *
Have teeth ever been injured due to an accidednt or a blows? *
If yes, when?
has patient ever sucked their thumb or fingers? *
if YES at what age did the patient stop?
When did you have your last Dental Check - Up
Do you have any outstanding general dental work to be completed?
Why have you brought your child come to see us? *

Family Background

Are there any other children in family?

Whom may we thank for referring you. *

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

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