Medical History Questionnaire

If you are a new patient requesting an appointment, we will need you to complete a medical history questionnaire providing us with information that will help us to treat your individual needs. This can be done at our practice before your appointment, online or you can print out our medical history questionnaire to complete at your leisure before your appointment.

Please fill in the online form below or if you prefer, please download Word version of the form and  email the form to info@thedentistshornsby.com.au

Welcome to Invisalign Dentist!

Thank you for giving us the opportunity to care for your oral health and smile. In order to provide high standard of care and treatment, please review and complete the following questionaire. It will be handled confidentially.

Title
First Name : *
Surname : *
Date of Birth :
Address :
Postcode :
Home Number :
Work Number :
Mobile Number :
Email Address *
Emergency Contact :
Private Health Fund :
Member Number :
If less then 18yrs, parent /responsible party:

How did you hear about the Practice?

 Internet/Website Yellow Pages Walked past Letter Drop Dentist/ Doctor Recommended by Other
Is another member of the family a patient at our office:  Yes No

What is the main purpose of your visit today?

Name of your G.P :
Phone :
Address :

Have you had any of the following Medical Issues?

Heart Problems / Disease :  Yes No
Blood Pressure :  Yes No
Artificial Joints :  Yes No
Rheumatic Fever :  Yes No
Heart Valve replaced/leaky :  Yes No
Circulatory Problems :  Yes No
Excessive Bruising /Bleeding :  Yes No
Liver or Kidney Disease :  Yes No
Radiation Treatment :  Yes No
Stomach Ulcers :  Yes No
Cancer :  Yes No
Sleep Apnoea :  Yes No
Psychological Disorder :  Yes No
Are you Pregnant?  Yes No
Allergies to Anaesthetic / Latex :  Yes No
Allergies to Penicillin :  Yes No
Allergies to Medications :  Yes No
Sinus Problems :  Yes No
Anaemia or other blood problems :  Yes No
Diabetes :  Yes No
Asthma :  Yes No
Epilepsy :  Yes No
Hepatitis A, B, C or D :  Yes No
Tuberculosis or CJD or HIV or AIDS :  Yes No
Infectious Diseases :  Yes No
Dizziness/Fainting :  Yes No
On Warfarin :  Yes No
if so, what is your due date?
Are you currently taking any medications?  Yes No
Are you taking or have you taken any Bisphosphonate drugs?  Yes No

If YES please provide details

Have you had any of the following dental issues?

Does your jaw click or hurt?  Yes No
Do you feel you grind your teeth?  Yes No
Orthodontic Treatment?  Yes No
Do you wear a guard at night?  Yes No
Sensitivity to hot or cold?  Yes No
Have you had gum Disease?  Yes No
Do you smoke?  Yes No
Bad Breath?  Yes No
Bleeding Gums  Yes No
Pain on bitting hard?  Yes No
Food jamming between teeth?  Yes No
Problems flossing?  Yes No

Other Notes or Concerns you would like us to know about?

How long since your last dental visit?
How often do you have dental examinations?
Previous dental xrays were taken:  Less than a year ago? Longer than a year ago?

Consent for Treatment

I hereby authorise the dentist or designated team to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I understand I can ask for a complete recital of any complications associated with treatment I may need. I agree to be responsible for payment of all sevices rendered on my behalf and on behalf of my dependents. I understand that payment is due at the end of service unless other arrangements have been made. I authorise that this information may be reviewed by team members of the dental practice.

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