Book Appointment Background InformationName* First Last Date of Birth* Address*Contact InformationHome Phone*Work PhoneMobile PhoneEmail* Appointment InformationReason for Appointment*Please SelectExamination and CleanFollow-up VisitExtractionEmergency (in pain)Emergency (broken tooth or filling)OtherOther Reason for Appointment*Preferred Day of the Week*Please SelectMondayTuesdayWednesdayThursdayFridaySaturdaySundayPreferred Appointment Time*Please SelectMorningAfternoonEveningHealth Insurer*Please SelectAHMAustralian UnityBUPACUADepartment of Veterans AffairsGMHBAHCFNIBMedibank PrivateTeachers Health FundNoneOtherOther Health Insurer*Request for details of your Medical HistoryIn order to provide you with the best possible dental care, and to limit the paperwork required when you arrive at our office, you may elect to provide us with more details regarding your Medical History.Do you wish to provide this additional information to speed up the registration process when you arrive at the surgery?NoYesMedical HistoryThis health history questionnaire will become a part of the patient’s dental record and will be considered confidential information. If there is anything you are unsure of please feel free to ask us on your arrival at the Surgery. All questions beyond this point are entirely optional, so feel free to complete as much or as little as you would like.Date of last Dental Visit Previous Dentists NamePrevious Dentists AddressTreating Doctors NamePrior Illness or HospitalisationHave you ever had any serious illness, operation, or been hospitalised in the past? If so, what was the illness or problem? Do you have any allergies?NoYesAllergiesPlease specify if you are allergic to any of the following items Asprin Penicillin Sulphur Drugs Latex Iodine Local Anaesthesia Opiates / Codine or Other Narcotics Any Metals or Plastics Any other substance Other AllergiesAre you taking any medications?NoYesCurrent MedicationsPlease specify which medications you are currently taking, why you are taking them, and how much you are taking.Name of MedicationForDosage Do you have, or ever had, any of the following diseases or problems? Heart Disease Congenital Heart Lesion Rheumatic Fever / Rheumatic Heart Disease Heart Murmers Heart Surgery Heart Valve Repair or Replacement Swollen Ankles / Feet Shortness of Breath Fainting or Dizziness Chest Pain Endocarditis Stent Placement (coronary, kidney, etc.) Heart Pacemaker Organ Transplantation (heart, kidney, lung, bone, etc.) Aneurysm Repair Stroke Diabetes Hypoglycemia Kidney Disease High Blood Pressure Low Blood Pressure Hives or Skin Rashes Respiratory Disease Hay Fever Asthma Use an Inhaler Chronic Obstructive Pulmonary Disease / Emphysema? Persistent Cough / Cough that produces Blood Tuberculosis Splenectomy Liver Disease Hepatitis A, B or C Jaundice Epilepsy / Seizure Disorder Stomach Ulcers Inflamitory Bowel Disease Arthritis / Joint Pain Blood Disease / Disorder Prolonged or Abnormal Bleeding Hemophilia Animia Sickle Cell Disease G-6PD Deficiency Thyroid Disease Autoimmune Disease Rheumatoid Arthritis Other Problems with the Immune System Sexually Transmitted Diseases Cold Sores / Herpes AIDS / HIV Persistent Diarrhea or Recent Weight Loss Persistent Swollen Glands in Neck Sinus Problems Tumors or Growths Cancer Glaucoma Nervousness Mental Illness Bipolar Disorder Eating Disorder Alzheimer Disease Blood Transfusion Joint Replacements Chemotherapy List any other diseases, conditions, or problems with your healthHave you ever had radiation treatment?NoYesIf yes, to what part of your body and when? Have you ever been treated with bisphosphonates such as Zometa, Aredia, Actonel, Fosamax, or Boniva?NoYesHave you ever taken antibiotics before dental treatment in the past?NoYesIf yes, what antibiotic?Are you on any steroid medications or have you ever been on steroid medications?NoYesIf yes, what medication and when?Women OnlyAre you Pregnant?NoYesAre you Nursing?NoYesAre you taking Birth Control Pills?NoYesEmailThis field is for validation purposes and should be left unchanged.
