Patient Health History Form

Health History Form
So we can ensure that we can provide you with the best possible care, you must answer all questions.
Patient Contact Details
Full Name
PrefixFirst NameMiddle NameLast Name
Preferred Name
Date of Birth
DayMonthYear
Gender
Occupation
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
This is my:
Phone Number
This is my:
Phone Number
E-mail
example@example.com
Welcome to our Practice
How did you hear about our practice?
Who can we thank for referring you to our practice?
In case of Emergency
Emergency Contact Name
Phone Number
General Practiitioner Name
Phone Number
Name of Medical Centre
Are you being treated by your GP or a Specialist at the moment?
NoYes
If yes, please give details
Your Medical History
Please tick to indicate that you have had the following conditions
Blood Pressure HighBlood Pressure LowArthritisArtificial JointsRheumatic FeverCirculatory ProblemsRadiation TreatmentExcessive BleedingExcessive BruisingKidney DiseaseStomach UlcersSinus TroubleCancerTumour HistoryAnaemiaAny Blood DisordersDiabetes 1Diabetes 2AsthmaEpilepsyHepatitis AHepatitis BHepatitis CHIV/AidsLiver DiseaseSteroid TherapyOsteoporosisAny other Bone DiseaseOther
Do you have any heart conditions?
NoYes
If yes, please give details
Has your GP or Specialist told you that you require antibiotic cover before dental treatment (related to heart conditions)?
YesNo
Ladies, are you pregnant?
YesNo
If yes, how many weeks?
Do you have any adverse reactions and/or allergies to any drugs or medications?
NoYes
If yes, please give details
Do you have any allergies to
LatexAnaestheticsOther
Are you taking any drugs or medications (including vitamins & herb supplements)?
NoYes
If yes, please give details (If you have a large list, you can upload a document or take a photo of your list on your phone below and submit it)
Upload a photo or document of your medication list
Cancelof
Take a photo of your medication list on your phone
Have you ever smoked?
NoYes
How long ago, for how long & how many a day
Your Dental History
Please tick if you have had any of the following conditions
Have you ever had a bad experience at the dentist?Does your jaw click or hurt?Do you feel you grind your teeth?Have you ever had orthodontic treatment?Do you wear a night guard?Have you ever had periodontal (gum) treatment?Do your gums bleed when you brush your teeth?Do you think you have bad breath?Do you ever experience sensitivity to hot/cold?Is there any other concerns about your teeth? (add details below)
Is there any other concerns about your teeth? If yes, please give details
Are you interested to see if we could offer any cosmetic procedures to your teeth?
NoYesUnsure
If yes, which procedures are you particularly interested in?
How long since your last dental appointment?
How often do you have dental examinations?
Have you had any dental x-rays in the past year?
NoYesUnsure
Preferred reminder method
What is your preferred reminder method, when confirming your appointments?
TelephoneEmailSMS
What is your preferred reminder method, when reminding your about your 6 monthly dental examinations & cleans?
LetterEmailSMS
Privacy & Confidential Information
I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist about this.
YesNo
I have recieved the Privacy Policy to read with this email as an attachment. I have read it and understood the policy.
YesNo
Terms & Conditions
Consent for Treatment:
1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
2. 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 the appropriate care.
3. I agree to the use of anaestheics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:
We expect and appreciate payment at the time of treatment. We accept Eftpos, Visa, Mastercard, American Express, personal cheque and cash.
We also can process your private health fund claim at the time of your appointment but need your card at every visit.
Cancellation Policy:
We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit.
I understand the consent for treatment, the payment and cancellation policies as stated above.
By my electronic signature below, I agree to the terms and conditions.
Date
MonthDayYear
Date
Signature
Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Part of our patient identifiers for the National Standards one of the patient identifiers is to upload a photo of each patient into our database.
Would you mind uploading a photo of yourself or taking a photo of yourself on your phone for your patient file.
Upload a photo of yourself for your patient file
Cancelof
Take a photo of yourself for your patient file
Should be Empty:

Health History Form

Patient Contact Details

Welcome to our Practice

In case of Emergency

Your Medical History

Your Dental History

Preferred reminder method

Privacy & Confidential Information

Terms & Conditions