Information and Medical History Form - Charlestown Road Dental

Patient Name*

Title First Last

Patient Date of Birth*

DD

MM

YYYY

Home Address*

Street Address City State Postcode

Provide your phone number*

Home Phone
Mobile Phone
Work Phone

Home Phone*

Mobile Phone*

Work Phone*

Email*

Occupation

Place of Work

Are you in a health fund for dental?

Yes
No

Do you have a voucher for Medicare “Child Dental Benefits Scheme” or Hunter New England Area Health Service “OHFFSS”?

Yes
No

Are you covered by Veterans Affairs (Repat)?

Yes
No

How did you come to our practice?

Personal referral (friend/family member/work colleague)
On-line/search (Google/search engine, Facebook, link etc)
Yellow pages
Saw surgery/signage as passing

Name of Personal referral

Please provide details

(Google/search engine, Facebook, link etc)

Medical Doctor

Medical History

Must be completed in full

1. Are you being treated by your doctor at present?

Yes
No

If Yes, please provide details:

2. Have you taken any medications, tablets or drugs in the past year?

Yes
No

If Yes, please provide details:

3. Are you allergic to any medicine or drugs?

Yes
No

If Yes, please provide details:

4. Have you experienced prolonged bleeding?

Yes
No

If Yes, please provide details:

5. Have you had any adverse reaction to dental treatment?

Yes
No

If Yes, please provide details:

6. Please tick any of the following which you have had:

Please provide details:

7. Women only: a) Are you on the contraceptive pill?

Yes
No

(certain medications prescribed may affect its effectiveness)

b) I am or may be pregnant

Yes
No

Approximate date of confinement, if known:

8. Is there anything confidential you would prefer to discuss with the dentist in private?

Yes
No

Please tick*

I confirm that the above is my/my child’s information and medical history, I am responsible for payment, and give my consent for dental treatment.

Name*

Dental Questionnaire

9. What is the main reason for your dental attendance?*

(eg check-up, toothache, sensitive tooth/teeth, broken tooth, bleeding gums, pain, swelling, discoloured tooth etc)

10. COVID-19 risk status declaration*

(Confirmed case/Suspect Case/At risk/Not at risk)

11. When was your last dental visit?

Last dental Xrays?

12. Do you attend regularly for check-ups, or do you usually only go to the dentist when something is wrong?

13. Does dental treatment make you excessively anxious?

Yes
No

14. What do you regularly use for home care of your teeth?

(eg brush, floss, mouthwash, etc)

15. Do your gums bleed when you clean your teeth, while eating, or ever spontaneously bleed?

Yes
No

16. Do you have problems chewing/biting?

Yes
No

17. Does food commonly impact between your teeth?

Yes
No

18. Are you unhappy with the appearance of your teeth?

Yes
No

19. Do you grind or clench your teeth, or have any jaw joint problems?

Yes
No

(eg clicking/locking/limited movement/pain)

20. Do you experience frequent or regular headaches?

Yes
No

21. Do you wake up still feeling tired, despite being asleep for a reasonable time? Or do you suffer daytime drowsiness?

Yes
No

(eg fall asleep readily and unexpectedly)

22. Do you have a dry mouth?

Yes
No

23. Have you been disappointed with any previous dental treatment?

Yes
No

If Yes, please provide details:

24. Any other concerns?