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How would you rate your health?
ExcellentGoodFairPoor
Are you being treated by a doctor at present? If so please give reason for treatment: YesNo
Have you been in hospital or had surgery in the past 12 months? If yes, give reason(s): YesNo
Are you taking or have you recently taken, any prescription or over the counter medications? YesNo If yes, please list all, including vitamins, natural or herbal preparations and/or diet supplements:
Please provide your usual doctor's name, address and telephone number:
Title
Date of Birth
Given Names
Surname
Parent/Guardian name (if patient is a minor)
Street number and name
Suburb
State
Postcode
Post Address (if different to residential)
Mobile Number
Home Phone (if different to mobile)
Work Phone
Email
Occupation
Preferred method of contact
LandlineMobileEmail
Emergency contact name
Emergency contact number
Relation MotherFatherWifeHusbandPartnerFriendSonDaughterGrandmotherGrandfatherBrotherSisterAuntUncleCousinNieceNephewNeighbourOther
GP Name
GP Contact Number
GP Clinic Address
GP Suburb
GP State
GP Postcode
Are you in a Private Health fund?
YesNo
Person responsible for payment of your treatment (if not yourself)
Medicare Number
Reference Number
Expiration Date
DVA Number
Type
Hospital Voucher
Select all that apply
AllergiesAnginaArtificial heart valveAsthmaArtificial jointBack ProblemBleeding disorderBlood pressureBlood thinner medicationCancerCardiac surgery/pacemakerChemotherapyCongenital heart defectCOPDCreutzfeldt Jakob DiseaseDiabetesDrug DependencyEndocrine DisordersEpilepsyFainting EpisodesGlaucomaHead/Neck InjuryHeart AttackHeart diseaseHeart murmerHeart Valve ReplacementHepatitis Type AHepatitis Type BHepatitis Type CHip/Knee ReplacementHIV PositiveHospital Acquired Infection eg. MRSAImmune deficiencyKidney DisorderMSMigraineNeurological disorderOsteoporosisProlonged BleedingPsychiatric careRadiotherapyRecurrent HerpesRefluxRheumatic feverRheumatoid arthritisSinusitisSteroid therapyStrokeThyroid disorderTuberculosisOther Liver Disease
Type of Allergies
Other
Comments
Please select one of the following:
Non-smokerSmokerEx-smoker
Are you pregnant?
Please insert due date
When was your last dental visit (approximately)
Have you ever had a reaction or complication following dental treatment in the past?
Do you have any private or confidential information you wish to discuss in private and not provide in writing?
Bad appearance of teethBad breathBleeding gumsDifficulty chewingDiscoloured teethDry mouthGrinding/clenching teethLoose teethLost filling/cavityMissing teethRapidly decaying teethPain in face/jawSensitive teethSounds from jaw jointSnoringSleeping problemsUnsatisfactory dentureWorn or broken teeth
Have you ever had a sleep study and/or been diagnosed with sleep apnoea?
Has anyone ever told you that you snore?
After 6-8 hours of sleep do you wake up refreshed?
Anything else you want to tell us?
Please advise any other relevant information you think we should know
By signing this form I consent to my relative to have check-up, clean & application of fluoride to the teeth or other treatment necessary and I am aware that I have the option of being present at the appointment and need to contact MDH prior to the date of their visit to book a suitable time.
Next of kin (specify your relationship with patient)
Son/ DaughterSpouseGuardianOther
Family/friendGP/DentistGoogle/webLocation search/online mapLocation/walk byFacebookInstagramSchool/preschoolPrint advertisementYellow pages/directoryUnsureOther:
Please check box below to indicate your consent
Any information is collected and maintained in accordance with State and Federal Privacy Legislation. I have accurately completed this medical history form to the best of my knowledge. I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
