Patient registration and medical history questionaire.Please complete the form below prior to your consultation appointment. If you prefer you can download and complete a paper version of this form. If you wish to complete this at the practice please arrive 15mins prior to your scheduled appointment. Click here to download the medical history form Name * First Name Last Name Salutation Mr Mrs Ms Miss Master Dr Prof Fr Gender * Male Female Other/ Not listed Preferred Pronouns He/him She/her Them/they Date of Birth MM DD YYYY Medicare number Parent/ Guardian/carer (if applicable) Person responsible for fees Self Other Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone * (###) ### #### Medical history questionaire Do you have any sores, growths or inflamed areas in or around you mouth? No Yes Has there been any change in your general health within the past year? No Yes Are you receiving medical care for an illness or condition? No Yes Have you been hospitalised in the past year? No Yes Do you have an ALLERGY or ADVERSE REACTIONS to LATEX or RUBBER PRODUCTS? No Yes Unsure Do you have an ALLERGY or ADVERSE REACTIONS to any DRUGS, MEDICATIONS or FOODS? No Yes Unsure Do you experience excessive bleeding, or have you experienced excessive bleeding after a medical or dental procedure? No Yes Have you ever had radiation therapy NOT INCLUDING x-rays taken for diagnostic purposes? No Yes Have you ever tested positive for HIV infection, AIDS, Hepatitis or other infectious diseases? No Yes Do you have any joint prosthesis (eg Hip, Knee, etc)? No Yes Have you ever had heart surgery, heart valve replacement or do you have any specific heart conditions? No Yes Have you ever been advised to take antibiotics prior to dental treatment? No Yes Have you been diagnosed with Diabetes? No Type 1 Type 2 Do you smoke or use tobacco products No Yes Previously (quit) Are you, or have you in the past required medications for the management of bone density such as bisphosphonates (eg Fosamax, Actonel, Zometa etc.) or denosumab (Prolia injections)? No Yes Do suffer from anxiety or fear with respect to dental treatment? No Yes Do you have, or have you had any of the following conditions? Please indicate all relevant conditions. Asthma Anaemia, excessive bleeding or other blood disorders Arthritis High Blood pressure Cardiovascular disease Congenital heart disease Cardiac pacemaker Tuberculosis Emphysema or lung disease Chronic cough or Bronchitis Hepatitis Epilepsy Fainting, dizzy spells or seizures Cancer Kidney disease Liver disease Sinus issues or hayfever Gastro-intestinal conditions or disturbances Gastric reflux Temporomandibular joint problems Chronic pain conditions Headache/Migraine Spinal or back related issues History of drug or alcohol abuse Immune deficiency or immunocompromised Osteoporosis or other bone conditions Thyroid disease Psychiatric illness or mental health issues Please indicate any other relevant conditions that are otherwise not listed Please list any current medications or drugs that you taking regularly. (You can bring or upload a list of medications if preferred) For ladies, are you currently pregnant? No yes Not applicable Medical doctor's name Medical practice name, address and contact details Thank you!
