Confidential Medical History Form

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? (Rate 1-10)* How happy are you with your smile? (Rate 1-10)* 1 2 3 4 5 6 7 8 9 10

Are you interested in whitening?* Are you interested in whitening?* Yes No

If yes, please list*

Are you pregnant?* Are you pregnant?* Yes No

If yes, when is the due date?

Any known allergies?* Any known allergies?* Yes No

If yes, please list

Any known reactions to anaesthesia? * Any known reactions to anaesthesia? * Yes No

If yes, please list

Do you require antibiotic cover BEFORE dental treatment? * Do you require antibiotic cover BEFORE dental treatment? * Yes No

Are you taking medication for bone disease? * Are you taking medication for bone disease? * Yes No

If yes, Please list*

Current Medication

Please indicate if you have, or have you ever had any of the following medical conditions? * 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

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Or Another Patient (Name)

Do you consent to your treatment discussions being recorded for treatment planning purposes? * Do you consent to your treatment discussions being recorded for treatment planning purposes? * Yes No