New Patient Registration

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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*:
    Date Of Birth:
    Private Address:
     
    Postcode:
    Business Address:
     
    Postcode:
    Telephone (Private)*:
    Telephone (Business):
    Mobile:
    Email:
    Occupation:
    Health Fund:
    Who recommended you to our practice?:
    Who is responsible for this account?:
    Medicare No.
    Next of Kin - Not living at your address
    Name:
    Address:
    Postcode:
    Telephone (Private):
    Your medical practitioner
    Name:
    Address:
    Postcode:
    Telephone (Private):
    If you are being treated by a doctor or naturopath at present, please tell us what for:  
    Please list all medications you are currently taking:  
    Please place a tick beside any of the following conditions which you have had:  
    Heart DiseaseRheumatic FeverHigh Blood PressureStrokeHeadache/ MigraineAsthmaSinus problemsTuberculosisSpinal, back or neck problemKidney DiseaseAnaemiaExcessive BleedingDiabetesEpilepsyCancer/LeukaemiaHepatitis AHepatitis BHepatitis CCold soresProsthetic Joint
    Details:  
    Are you in a high risk health group? Do you use drugs of addiction
    YesNo
    Have you ever had a blood transfusion or received blood products?
    YesNo
    Have you been in hospital in the past year?
    YesNo
    Have you had any abnormal reactions to injections, drugs or materials during dental treatment?
    YesNo
    Are you allergic to any medicines? e.g. penicillin Do you react to any metals or jewellery?
    YesNo
    Do you smoke?
    YesNo
    Have you had a difficult extraction or a dry socket?
    YesNo
    Have you had prolonged bleeding after extractions?
    YesNo
    Women - If pregnant, state expected date of delivery
    YesNo
    DENTAL HISTORY
    When did you last visit the dentist?  
    Do you have any fear or anxiety about dental treatment? If so, what of?  
    Have you had any teeth removed?  
    Do you chew on both sides of your mouth?  
    Do you use dental floss?  
    Do your gums bleed?  
    Do you think you have bad breath?  
    Does food wedge between any of your teeth?  
    Do your jaw joints click or lock?  
    Do you clench or grind your teeth?  
    Have you had orthodontic treatment?  
    Are you happy with the appearance of your teeth?
    Further comments
    Patient / Guardian's signature:
    Date: