Dental at Coorparoo Patient Medical / Dental History Form

We would like to welcome you to our practice. To assist us in providing you with the best possible treatment and standard of care, we ask that you complete this confidential medical / dental history questionnaire.

Patient Information
Last Name *
Title *
First Name *
Date of Birth *
Address *
Suburb *
Postcode *
Ph (home) *
Ph (work)
Ph (mobile)
E-mail *
Private Health Fund Name ? (ie: HCF, MBF, BUPA...)
If DVA, enter your membership number

How did you hear about us?
Referral Source

Emergency Contact
Emergency Contact Name
Emergency Contact Phone No.
Emergency Contact Relationship

Responsible Party for Billing
All accounts are to be settled at the end of each appointment. If a carer / guardian / parent is responsible for settling the account, please give details, or leave blank if these are the same as above:
Address (if different from above)
Contact Phone No.

Medical History
I have confidential medical information that I do not wish to write down. I would prefer to speak to a dentist about this.
Do you normally require antibiotic cover before dental treatment ?
Have you had any abnormal reactions to local or general anaesthesia ?
Do you smoke ?
Are you pregnant ? (females only)
Are you being treated by a doctor at present ?
Are you taking ANY PRESCRIPTION or other medications at present ?
Have you been hospitalised in the last 12 months ?
Have you or anyone in your household returned from overseas travel in the last 10 days ?

Who is your Medical Practitioner (GP) ?
Medical Practitioner's Phone No
Are you taking any of these medications?
What medications, including natural remedies are you taking? (Please specify):
Are you allergic to anything? eg local anaesthetic, latex, penicillin, peanut etc:
Is there anything else about your health you believe we should know? (Please specify):

Medical Conditions
Do you have now, or have you ever had, any of the following medical conditions ? (Please tick YES or NO for each condition)
Steriod therapy *
Rheumatic Fever *
Epilepsy *
Asthma *
Diabetes *
Heart Disorder / Complain *
Bone disease, including osteoporosis *
Radiation therapy *
Kidney disease *
Excessive bleeding *
Stroke *
Cancer *
Tuberculosis *
Thryoid disease *
Nervous or psychiatric condition *
High or Low blood pressure *
Prosthetic implant eg artificial hip *
Cardiac pacemaker *
Stomach or digestive condition *
Hepatitis or other liver diseases *
Contact with blood-borne viruses *
Bronchitis, emphysema or other lung diseases *
Anaemia, leukaemia or other blood diseases *
Any other condition (specify below) *
Any other condition(s) not mentioned in the above list (please list):

Concerns or Problems
Please list any concerns or problems that you have with your teeth or mouth

Future Marketing
Do you want to receive future practice news or promotions from us ?

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Thank you.