MEDICAL/ DENTAL HISTORY
WELCOME! So that we may provide you with the best possible care, please complete BOTH SIDES of this
Medical/Dental History Form. All information is treated with complete confidentiality.
_______________________________________________________________Date of Birth: ____/ _____/ ___
Dr / Mr / Mrs / Miss / Ms First Names
Surname
Home Address: ___________________________________ _______________________________________
Suburb:
___________________________________ State: ___________ P/code: _______________
Home Phone:
_____________________________
Mobile: ___ ___________________________
Work no.
_____________________________
Email: _________________________________
Occupation:
_____________________________
Company: ______________________________
How would you like to be contacted? (PHONE)
(EMAIL)
(SMS)
(MAIL)
Are you with a Private Heath Fund? ________________________ Are you a DVA Card Holder? ____________
Who can we thank for referring you to the practice? ______________________________________________
Details of person to contact in an emergency: Name: _____________________________________________
Relationship?____________________ _________ Contact Number: ________________________________
DENTAL HISTORY
What is the reason for your visit today? _________________________________________________________
Date of last dental visit?___________ Date of last cleaning?_____________ Date of last x-rays?____________
What was done at your last dental visit?_________________________________________________________
Previous Dentist? ___________________________________________________________________________
How often do you have dental examinations? ____________________________________________________
How often do you brush your teeth?___________________ How often do you floss? ____________________
What other aids do you use? (electric toothbrush/ waterflosser/interedental brush etc)__________________
Do you have any dental problems now?
Yes / No
If yes please describe: _______________________________________________________________________
Are any of your teeth sensitive to:
Have you ever had:
Hot or cold?
Yes
No
Orthodontic treatment?
Yes
No
Sweets?
Yes
No
Oral surgery?
Yes
No
Biting or chewing?
Yes
No
Periodontal treatment?
Yes
No
Mouth odours or bad tastes?
Yes
No
Do your gums bleed or hurt?
Yes
No
Blisters or oral lesions?
Yes
No
Family history of gum disease?
Yes
No
Teeth ground/bit adjustment?
Yes
No
Family history of tooth loss?
Yes
No
Bite plate or mouthguard?
Yes
No
Problems with dental infections?
Yes
No
MEDICAL/ DENTAL HISTORY
Do you:
Have you experienced?
Clench or grind your teeth?
Yes
No
Clicking or popping of the jaw?
Yes
No
Bite your lips or cheeks regularly? Yes
No
Pain (joint,ear,side of face)?
Yes
No
Breathe through your mouth?
Yes
No
Difficulty opening/closing?
Yes
No
Have tired jaws- especially in am? Yes
No
Difficulty chewing?
Yes
No
Are you satisfied with your teeth’s appearance?
Yes
No _____________________________________
Are you nervous about dental treatment?
Yes
No _____________________________________
Is there anything else about having dental treatment you would like us to know?
_________________________________________________________________________________________
MEDICAL HISTORY
1. Are you receiving any medical treatment at the present time?
Yes / No
Details: _______________________________________________________________________________
2. Please list any medication you are taking:
______________________________________________________________________________________
3. Have you experienced any allergies or unusual effects from any tablets, drugs, injections or anaesthetic?
Details: ________________________________________________________________________________
4. Are you or have you ever been a smoker?
Yes / No
5. Have you ever had any of the following? If so, please tick as appropriate.
 Rheumatic Fever
 Epilepsy
 Heart Trouble
 Anaemia
 High Blood Pressure
 Diabetes
 Asthma
 Kidney Trouble
 Arthritis
 Gastric Problems
 Hepatitis - Specify type A, B, C
 Cold Sores
 Bronchitis or Chest Problems
 Depressive Illness
 Severe Headaches
 Drug Dependence
6. Have you had any prosthetic surgery?
Yes / No
7. Are you HIV positive?
Yes / No
8. Are you at risk to HIV exposure?
Yes / No
9. LADIES:
Are you pregnant?
Yes / No
Nursing?
Yes / No
Taking birth control pills?
Yes / No
I understand that payment is required at the completion of treatment (unless a financial agreement has been arranged prior to
the appointment) and 24 hours notice is required if I am unable to attend my scheduled appointment, or a fee may be charged.
Signed: Patient/Parent/Guardian _____________________________________
Date: _____________