Medical History Form

Personal Details

First Name*

Surname*

Date Of Birth*

Address*

Postcode

Email Address*

Mobile Phone*

Employer*

Employer Phone No.*

Emergency Contact*

Phone*

Relationship*

Refferring Dentist*

Health Fund Name

Your Doctor

Practice Name

Medical History

Please tick any that apply to your medical history

Other (Please state)*

Are you pregnant?*

Yes

Due Date

(If yes please indicate due date)

Is personal stress a significant part of your life?*

Yes

Details

(If yes please give details)

Do you smoke/vape?

Current

Amount per day

(If current please mention amount per day)

Do you smoke/vape?

Past

Quit Date

(If past give quit date)

Has your GP (Doctor) prescribed Antibiotics for ALL Dental Treatment*

Yes

Details

(If yes give details)

Recent heart valve replacement?*

Yes

When

(If yes please mention when)

Details

(If yes please give details)

Do you have any allergies?*

Yes

If yes please list all allergies/reactions

Do you currently take any Medication?*

Yes

If yes please list all medications

Dental History

NAME OF YOUR CURRENT DENTIST/PRACTICE*

DATE OF LAST VISIT

REASON FOR VISIT

HAVE YOU HAD COMPLICATIONS FOLLOWING PREVIOUS DENTAL TREATMENT?

(If yes, please explain)

Are you anxious about dental treatment?*

Completely comfortable (1) Completely terrified (10)

Did you receive any of the following

Please explain your reaction to anaesthetic*

Please explain your crown treatment*

Do you use*

Manual toothbrush

Electric toothbrush

Floss

Piksters

How often do you brush each day?*

Terms & Conditions

I authorise the doctor or designated staff to undertake examination, x-rays, study models, photographs and other diagnostic aids as deemed appropriate.
I understand that some of our clinicians may use a recording device in their surgery for note taking purpose.
Upon such diagnosis, I authorise the doctor to perform all recommended treatment mutually agreed upon and to employ such assistance as required.
I understand that the time set aside for my appointment is important, and failure to provide at least 48 hours notice of changes or cancellation may incur a broken appointment fee.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependants. Payment in full is due on the day of appointment.

Images & Photos

As part of your dental treatment, photographs and/or images may be taken to assist in diagnosis, planning, treatment, and monitoring of your oral health.

With your permission, these images may also be used for educational, training, or promotional purposes.

Types of Use (Please tick):

Clinical Records Only

Educational Use

Promotional/Marketing Use

Declaration & Consent

I declare that the above information is true and correct to the best of my knowledge.
If there are any changes to my medical history, I will notify the treating clinician as soon as possible.

I have read and agreed to the terms and conditions as set out above and as advised by Cairns Specialist Dental.

Name Of Patient*

SIGNATURE OF PATIENT*

Date*

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