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.





CREATING SMILES, CHANGING LIVES





CREATING SMILES, CHANGING LIVES





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Copyright by Integrated Dental Care 2018. All rights reserved.




Copyright by Integrated Dental Care 2018. All rights reserved.