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    2. Confidential Medical History Form

    Your Details

    It is important for us to know details about your medical history as these could affect the success of your oral health care. The information provided is confidential and will be handled in accordance with our privacy policy.
    First Name
    Last Name
    Date of Birth
    Occupation
    Address
    Email
    Phone (Home)
    Phone (Mobile)
    Phone (Work)
    Interests
    Private Health Insurance

    Your Emergency Contacts

    Emergency Contact Name
    Phone
    Relationship
    Doctor's Name
    Doctor's Phone

    Your Health

    How happy are you with your smile? *
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    Are you interested in whitening? *
    Yes
    No
    How long since your last dental visit?
    Are you pregnant? *
    Yes
    No
    Due Date
    Any known allergies? *
    Yes
    No
    If yes, please list
    Any known reactions to anaesthesia? *
    Yes
    No
    If yes, please list
    Do you require antibiotic cover BEFORE dental treatment? *
    Yes
    No
    Are you taking medication for bone disease? *
    Yes
    No
    If yes, please list
    Current medications
    Please indicate if you have, or have you ever had any of the following medical conditions? *
    Asthma
    High | Low Blood Pressure
    Smoker
    Diabetes
    Cold Sores
    Excessive Bleeding
    Hepatitis A | B | C
    HIV | AIDS
    Rheumatic Fever
    Bronchitis, Emphysema or Lung Condition
    Stroke
    Tuberculosis
    Heart Murmur
    Heart Complaint
    Cardiac Pace Maker
    Heart Valve Disorder
    Thyroid Disease
    Kidney Disease
    Epilepsy
    Radiation Therapy
    Stomach or Digestive Condition
    Prosthetic Implant
    Osteoporosis
    Transplant: Organ | Marrow
    Anaemia, Leukaemia or other Blood Diseases
    Grinding / Clenching
    Sleep Aids (e.g. CPAP)
    Sleep Study
    Snoring
    Additional notes or conditions
    Referred By
    Health Fund
    TV Advert
    Yellow Pages
    Street Sign
    Facebook
    Google
    Or Another Patient (Name)
    Do you consent to your treatment discussions being recorded for treatment planning purposes? *
    Yes
    No

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    07 4725 3324

    199 Ross River Road, Aitkenvale
    Townsville, Queensland, 4814

    PO Box 296 Aitkenvale
    QLD 4814

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