Retrieve my history
Healthy Smile Dental New Patient / Medical History Form
New patient
Existing patient
Underwood branch
Calamvale branch
Title:
Mr.
Mrs
Miss
Ms.
Dr.
Date of Birth
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First Name:
Surname:
Address:
Suburb:
Postcode:
Home phone:
Mobile:
E-mail:
Occupation:
*
Private Health Fund:
Yes
No
Emergency Contact Name:
Relationship:
Emergency home/mobile phone no.:
How did you hear about this practice :
Internet
Walk by
Insurance
Others
Personal Referral
Do other family members attend this practice:
Yes
No
Please give full name(s)
How would you prefer to be contacted to confirm your appointments?
Phone
Text Message
Email
Do you require antibiotic cover before receiving dental treatment?
Yes
No
Have you had any abnormal reactions to local or general anaesthesia?
Yes
No
Do you smoke?
Yes
No
Are you pregnant?
Yes
No
Are you being treated by a doctor at present?
Yes
No
Are you taking any prescription or over-the-counter medications at present?
Yes
No
Please list your current medications - if applicable:
Who is your medical practitioner?
Ph:
Please list any known drugs or food you might be allergic to:
Do you have now, or have you ever had, any of the following medical conditions?
Steroid therapy
Yes
No
Kidney diseases
Yes
No
Prosthetic implant e.g. artificial hip
Yes
No
Tuberculosis
Yes
No
Excessive bleeding
Yes
No
Bone disease, including osteoporosis
Yes
No
Epilepsy
Yes
No
Radiation therapy
Yes
No
Stomach or digestive condition
Yes
No
Asthma
Yes
No
Cardiac pacemaker
Yes
No
Hepatitis or other liver diseases
Yes
No
Diabetes
Yes
No
Rheumatic fever
Yes
No
Contact with blood-borne viruses
Yes
No
Thyroid disease
Yes
No
Heart disorder/complaint
Yes
No
Bronchitis, emphysema or other lung diseases
Yes
No
Nervous or psychiatric condition
Yes
No
High / low blood pressure
Yes
No
Anaemia, Leukemia or other blood diseases
Yes
No
Latex allergy
Yes
No
Details or any not mentioned (please list):
When was your last dental treatment?
What is the purpose of today’s visit?
What did you like or dislike about your previous dental experience?
Are you happy with your smile? Discuss your concerns and treatment options with our dentists.
What dental concerns do you have?
Sensitive teeth (hot/cold)
Yes
No
Loose teeth
Yes
No
Discoloured teeth
Yes
No
Toothache
Yes
No
Lost filling/cavity
Yes
No
Crowded teeth
Yes
No
Bleeding gums
Yes
No
Worn/broken teeth
Yes
No
Wisdom teeth
Yes
No
Missing teeth
Yes
No
Clicking of jaw joints
Yes
No
Other concerns
Yes
No
Patient Declaration
I hereby declare that the information provided on this form is true & correct,
and agree to provide payment by Cash, Eftpos or VISA/Mastercard on the day of treatment.
For future appointment bookings, our practice policy is that we require 48hrs notice for rescheduling an appointment. A cancellation fee may apply if inadequate notice is given.
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Year
2014
2015
2016
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