Medical History Form

Welcome To The Dental Group

Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.

Please Select  :  
MrMrsMsMissMasterDr

Surname*:

First Name*:

Address:

Suburb:

Postcode:

Preferred Phone Number*:

Email:

Preferred Method of Contact:
PhoneEmail

Date Of Birth:

Occupation:

Parent/Guardian names if under the age of 16:

Are you in a Private Health Fund for Dental? If yes, which one?  

Are you covered by Veterans Affairs? If yes, card number?  

How did you find out about Our Practice?  
AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther

Have you ever had or do you have any of the following? (Please tick)

Asthma or Bronchitis. If yes, which one?  

HIV or Hepatitis A,B or C. If yes, which one?  

Hip/Knee Replacement. If yes, which one?  

Anxiety or Depression. If yes, which one?  

Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:

Other serious injury or illness:

List any medication you are currently taking:

GP's Name and location:

Signature:

Date: