Medical History FormPlease complete the Medical History Form before your first appointment with us. You can either fill it in online or download and print it out here and bring it in when you come to see us. Name* Mr.Mrs.MissMs.Dr. Title First Name Surname Preferred NameDate of Birth* DD MM YYYY Home Address* Street Address City State / Province / Region ZIP / Postal Code OccupationHome PhoneMobile Phone*Medicare*Email* Emergency ContactEmergency Contact (next of kin)Emergency Contact (next of kin) Mobile phoneContact details of your doctor/medical GPDental InsuranceDental Insurance CompanyMembership NumberID NumberAre you Aboriginal or Torres Strait Islander?YesNoIs English your 2nd language?YesNoYour first language is?Is another member of your family a patient at our Practice?YesFamily member nameHOW DID YOU HEAR ABOUT US?*Word of mouthWork in the areaInternetFacebookLive in the areaHealth Fund referralIf Word of Mouth, who recommended you?Please select any of the below that are relevant to you. Heart Problems Pacemaker Blood Pressure Artificial joints Rheumatic fever Allergies Asthma Stroke Transplanted organ or bone marrow Tuberculosis Smoker Cancer Liver or Kidney Problems HIV/AIDS Circulatory problems Radiation treatment Excessive bleeding or bruising Diabetes Stomach Ulcers Anemia or blood disorders Hepatitis Sinus trouble Antibiotic cover prior to dental treatment Bone density problems Epilepsy Alcoholism Mental Health Issues Drug or Alcohol addiction Visual Impairment Hearing Impairment Rheumatism Arthritis Osteoporosis Other Please listWhat medications or supplements are you currently taking? (including recreational drugs)Have you ever been prescribed the following medications? Zometa™ Pamidronate™ Bonitas™ Actonel™ Fosamax™ Prolia™ Previous dental historyWhen was your last dental appointment?How often do you have dental examinations?Previous dental x-rays were takenLess than a year agoLonger than a year agoInformation about you and your dental needsDesired outcome from today’s visitWhat concerns do you have about dental treatment? Fear Pain Cost Time Constraints Other Please listDo any of the following apply to you?Tick for Yes Do you dislike your smile? Do you think you have bad breath? Have you any gaps or spaces in your teeth that stop you from eating food properly? Do your gums ever bleed when you brush or floss your teeth? Do you dislike the colour of your teeth? Do you experience sensitivity with hot/cold? Do you think you have uneven teeth? Does your jaw click or hurt? Have you any silver/black fillings that you wish were white? Do you think you grind your teeth? Do you have any teeth that appear too small, short, large or long? Do you bite your lips or cheek often? Do you have any prior dental work that appears unnatural? Do you feel nervous about dental treatment? Do you have any crowns or bridges that appear dark at the edge of your gums? Have you used Botox to treat jaw joint dysfunction? Please use this space if there is anything else you would like us know about you or your oral health goals.DECLARATION: In submitting this form I acknowledge that this represents an accurate medical history. I will advise my dentist of any changes to my medical history in the future. I understand that all medical details will be treated with complete professional confidentiality. I have read the privacy document provided by this practice.