Medical History Form


    Title:

     

    Residential Address:

     

    Postal Address (If different to above):

     

    Emergency Contact:

     

    Person Responsible For Fees:

     

    Do you have Dental Insurance?YesNo

     

    Where did you hear about us?

    Who recommended you to this practice?

     

    Do you consent to the Privacy Policy?YesNo

     

    MEDICAL AND DENTAL INFORMATION

    Are you allergic to any drugs, medicines or foods?YesNo

     

    Have you ever had any of the following?

    Rheumatic Fever

    YesNo

    Rheumatoid Arthritis

    YesNo

    Osteo Arthritis / Porosis

    YesNo

    Asthma

    YesNo

    Diabetes

    YesNo

    Kidney Disease

    YesNo

    Latex Allergy

    YesNo

    Radiation Treatments

    YesNo

    Sinus Trouble

    YesNo

    Lung Disease

    YesNo

    Excessive Bleeding

    YesNo

    Epilepsy

    YesNo

    Heart Ailment

    YesNo

    High Blood Pressure

    YesNo

    Jaundice or Hepatitis

    YesNo

    Bowel Disease

    YesNo

    Bone Disease

    YesNo

    Stomach Ulcers

    YesNo

    Tumor History

    YesNo

     

    Have you had trouble with previous dental experiences? YesNo

    Does your jaw ‘click’ or hurt? YesNo

    Do you feel you grind your teeth? YesNo

    Have your teeth worn down and become discoloured? YesNo

    Have you previously worn a night guard? YesNo

    Have you had issues with jaw problems? YesNo

    Do you like the arrangement of your teeth? YesNo

    Do you like the shape of your teeth? YesNo

    Do you like the colour of your teeth? YesNo

    Do you have spaces between your teeth? YesNo

    Does the appearance of your teeth bother you? YesNo

    How would you rate your smile now (out of 10)

    What are your expectations for your new smile?

    Do your gums bleed when you clean your teeth? YesNo

    Do you feel you suffer from bad breath? YesNo

    Have you had previous gum health problems? YesNo

     

    Are you taking bisphophonate medications? YesNo

    When was your last dental x-ray taken?

    Do you smoke tobacco? YesNo

    Are you pregnant? YesNo

    Do you have any artificial hip, heart valve or prosthetic implant? YesNo

     

    State ALL medications that you are currently taking.




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    CREATING SMILES, CHANGING LIVES





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    Copyright by Integrated Dental Care 2019. All rights reserved.




    Copyright by Integrated Dental Care 2019. All rights reserved.