Confidential Medical History Your Details Prefix Mr. Mrs. Miss Ms. Dr. First Name * Surname * Date of Birth * Street Address * Town/City * Postcode * Occupation Email * Home Phone Mobile Contact Preference * Mobile/SMS Email Home phone Parent or Guardian How did you hear of us? We like to thank those who refer. If someone recommended us, please let us know so we can send them a coffee card and enter them in our monthly prize draw! Doctors Information Name of Doctor Practice name Practice phone Emergency Information Emergency Contact Emergency Contact Phone Relationship Medical Health Assessment Heart * Rheumatic Fever Heart Murmur High Blood Pressure Angina Heart Surgery Thrombosis Pacemaker Fitted Other Heart condition None Details Blood Hepatitis B Anaemia H.I.V. Sickle Cell Abnormal Blood Test Result Blood refused by transfusion service Other Blood condition If yes, details/medication Allergies / Reactions * Penicillin Eczema Aspirin Latex Anti-Tetanus Serum Plants Medicines Foods Reaction to General Anaesthetic Hay Fever Reaction to Local Anaesthetic Other Allergy None Details Chest COPD Asthma Other Chest Condition If yes, details/medication Warnings * Pregnant or possibly pregnant Problem being reclined Antibiotic Cover required Steroids in last 2 years Warning Card/Bracelet Anything else your dentist should know Bruising or persistent bleeding after injury, surgery or tooth extraction Currently under treatment of a doctor, hospital or clinic Any other treatment that required you to be hospitalised None Details Other Liver Disease (e.g. jaundice) Kidney Disease Diabetes / Family with Diabetes Epilepsy Acid Reflux or Eating disorder Bone or Joint disease Cancer Artificial Joint Fainting Attacks or Blackouts Giddiness - Vertigo If yes, details/medication Medication List and state doses for any prescribed medicines, tablets, ointments, injections, inhalers (inc. contraceptives and HRT) or recreational drugs you are taking that have not already been listed: Habits Smoke tobacco products (Per day) High sugar / Frequency Fizzy/acidic/sugary drinks Details Confidential Oral Health Survey What is the purpose of your visit? Who was your previous dentist? Have you ever experienced dental anxiety? Please tell us about your oral health. Tick any of the statements below that apply to you. Appearance I feel self-conscious when I smile. I am dissatisfied with the appearance of my teeth. I have whitened (bleached) my teeth in the past. I have irregularly positioned (crooked or spaced) teeth that I dislike. I have chips or gaps in my teeth that worry me. I have missing teeth that concern me. Gum and Bone My gums appear red and swollen, or bleed and are painful when brushed or flossed. I have been treated for gum disease or been told I have lost bone around my teeth. I have noticed an unpleasant taste or odour in my mouth. I have noticed my gums have started receding. I have noticed my teeth are starting to become loose and I have difficulty chewing hard foods. There is a history or periodontal (gum) disease in my family. Bite and Jaw Joint I have problems with my jaw joint (pain, sounds, limited opening, locking). I have problems chewing gum. I have problems chewing hard foods. My teeth have changed (become shorter, thinner, warn) in the last 5 years. I have more than one bite position and squeeze to make my teeth fit together. I bite my nails or cheek, use teeth to hold objects, or have other oral habits. I clench my teeth in the daytime and they become sore. I have problems sleeping or wake with an awareness of my teeth. I have/do wear a bite appliance at night to protect my teeth. Tooth Structure I have had cavities in the last 3 years. I have dry mouth or have difficulty swallowing food. I noticed holes (pitting, craters) on the biting surface of my teeth. My teeth are sensitive to hot, cold, biting, sweets and I sometimes avoid brushing parts of my mouth. I snack between meals. I have sugar in my tea or coffee. I drink fruit juice or fizzy drinks between meals. I have grooves or notches on my teeth near the gum line. I have had broken/chipped teeth, or had a toothache or cracked filling. I frequently get food caught between my teeth. If you could change your smile, what would you most like to change? I would like my dentist to send me information relating to the answers I have given. I would like to be contacted about important notifications I would like to receive practice newsletters I would like to receive information about products & service or promotions. Consent * I confirm that the information above is true and correct to the best of my knowledge Privacy Policy * Our Practice follows the rules set out below whenever we collect, use, store or disclose information about your health. Collecting your health information – When we collect health information from you we will... - Only collect the information for the purpose of treating you (or for some related purpose) - Collect information directly from you unless you have authorised us to collect the information from someone else (or we have some other lawful reason for collecting the information from someone else); and - Tell you why we are collecting the information and what we will do with it. Using your health information – We will not use your health information for any purpose other than for the purpose of treating you unless we get your consent or we will use your information in a way that doesn’t identify you (or where we have some lawful reason for doing so). Storing your information – We will store your health information securely so that only authorised people can access or use your information. Disclosing your health information – We will not disclose your health information to anyone without your consent unless we have a lawful reason for doing so. Access and correction of your health information – You can ask us to confirm whether we hold information about you. If we hold information about you, you have the right to access the information. You can ask us to correct any information that we hold about you if you think that the information is inaccurate. If we refuse to correct your information, you can ask us to put a note on your information that states that you have asked for the correction to be made. Enquiries – If you have any concerns about any matter relating to your health information, please ask to speak to our privacy officer. I agree to the privacy policy. Payment Please note that payment is required at the time of treatment. All cost in relation to collection of overdue accounts will be added to your account. Appointments not kept, failed, or cancelled without 48 hours’ notice may incur a charge. We gladly accept EFTPOS, Visa, MasterCard, and Q-Card. We can also process payments through Southern Cross Easy-Claim for those with dental cover. Appointment Changes 24 hours notice is required for appointment changes. Missed appointments or short notice cancelations may attract a fee. Thank you for completing the form.
