Medical History Form

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    Welcome To The Dental Group

    Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.

    Please Select Location*:
    Please Select  :  
    MrMrsMsMissMasterDr
    Surname*:
    First Name*:
    Address:
     
    Suburb:
    Postcode:
    Preferred Phone Number*:

    Email:

    Preferred Method of Contact:
    Date Of Birth:
    Occupation:
    Parent/Guardian names if under the age of 16:

    Are you in a Private Health Fund for Dental? If yes, which one?  

    Are you covered by Veterans Affairs? If yes, card number?  
    How did you find out about Our Practice?  
    AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther
    Have you ever had or do you have any of the following? (Please tick)
    High Blood Pressure
    YesNo
    Diabetes
    YesNo
    Heart Conditions or Heart Surgery
    YesNo
    Arthritis
    YesNo
    Excessive Bleeding
    YesNo

    Asthma or Bronchitis. If yes, which one?  
    Rheumatic Fever
    YesNo

    HIV or Hepatitis A,B or C. If yes, which one?  

    Hip/Knee Replacement. If yes, which one?  
    Epilepsy
    YesNo

    Anxiety or Depression. If yes, which one?  
    Hay Fever or Sinus
    YesNo
    Allergies
    YesNo
    Ladies, are you pregnant?
    YesNo
    Radiation therapy to the head or neck
    YesNo
    Treatment therapy for cancer
    YesNo


    Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
    Other serious injury or illness:
    List any medication you are currently taking:
    GP's Name and location:
    Signature:
    Date: