www.smileinstyle.com.au - Medical History Update Form

Medical History Update Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Information
Title
Gender*
If "Other" Please Specify
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Home Address*

Street Address Line 2

City

Postcode
Suburb*

Suburb

Street Address Line 2

City

Postcode
State*
Postcode*

Street Address Line 2

City

Postcode
Home Phone Number*
Mobile Phone Number
Work Phone Number
Email Address*
example@example.com
Occupation
Health Insurance
Member ID Number
Contact person in case of emergency
Phone/Mobile Number
Would you like to subscribe to our newsletter?*

YesNo
Medical History
Are you being treated for a medical condition?*

YesNo
If Yes, Explain*
Medical Doctor's Name

First NameLast Name
Doctor’s Address*

Street Address Line 2

City

Postcode
Suburb*

Street Address Line 2

City

Postcode
State*
Postcode*

Street Address Line 2

City

Postcode
Phone Number
Are you taking any medications or supplements at present, both prescribed or over the counter?*

YesNo
If Yes, Please list*
Are you taking any bisphosphonate medication or any other medication to treat osteoporosis?*

YesNo
If Yes, Explain *
Do you have, or have you ever had, any of the following medical conditions?

Steroid therapyRheumatic feverEpilepsyAsthmaDiabetesHeart valve disorderStrokeHeart murmurKidney diseaseTuberculosisEating disorderLeukemia, cancerNervous conditionHeart complaintHeart surgeryThyroid diseaseRadiation or chemo therapyHigh blood pressureLow blood pressureStomach or digestive condition e.g. refluxTransplanted organ or bone marrowCardiac pacemakerExcess bleedingHepatitis or liver diseaseContact with HIV/AIDS virusAnaemia or Blood DisorderProsthetic implant eg. prosthetic hip or kneeBronchitis, emphysema or other lung diseaseHeart complaint or heart surgeryOther
Do you have allergies?*

YesNo
What reaction do you have to allergies, please list.*
Do you smoke?*

YesNo
How many /day?
Do you Vape?*

YesNo
If so, how often
Are you pregnant or undergoing fertility treatment?*

YesNo
If Yes, Explain *
Guardian Name*

First NameLast Name
Dependents
Your Signature*

Clear
Date*

DayMonthYear
Date
Please verify that you are human*
Should be Empty:

Medical History Update Form

Patient Information

Medical History