Medical History Questionnaire

If you are a new patient requesting an appointment, we will need you to complete a medical history questionnaire providing us with information that will help us to treat your individual needs. This can be done at our practice before your appointment, online or you can print out our medical history questionnaire to complete at your leisure before your appointment.

Please fill in the online form below or if you prefer, please download Word version of the form and  email the form to info@thedentistshornsby.com.au

Click for PDF version of The Dentists Hornsby Medical Form

Welcome to The Dentists Hornsby!

Thank you for giving us the opportunity to care for your oral health and smile. In order to provide high standard of care and treatment, please review and complete the following questionaire. It will be handled confidentially.

* required

Email *:
Title:
First Name *:
Surname *:
Date of Birth:
Address:
Postcode:
Home Number:
Work: Number:
Mobile Number:
Occupation
Emergency Contact
Private Health Fund:
Member Number:

If less than 18years old, parent/responsible party:

How did you hear about the Practice?

Internet/WebsiteYellow PagesWalked pastLetter DropDentist/ DoctorRecommendedOther

If Doctor/Dentist please state who:
If Recommended, who by:
If Other, please specify

Is another member of the family a patient at our office: yesno

What is the main purpose of your visit today?

Name of your GP:
Phone :
Address:

Have you had any of the following Medical Issues? please tick

Heart Problems / Disease yesno
Blood Pressure yesno
Artificial Joints yesno
Rheumatic Fever yesno
Heart Valve replaced/leaky yesno
Circulatory Problems yesno
Excessive Bruising /Bleeding yesno
Liver or Kidney Disease yesno
Radiation Treatment yesno
Stomach Ulcers yesno
Cancer yesno
Sleep Apnoea yesno
Psychological Disorder yesno
Allergies to Anaesthetic / Latex yesno
Allergies to Penicillin yesno
Allergies to Medications yesno
Sinus Problems yesno
Anaemia or other blood problems yesno
Diabetes yesno
Asthma yesno
Epilepsy yesno
Hepatitis A, B, C or D yesno
Tuberculosis or CJD or HIV or AIDS yesno
Infectious Diseases yesno
Dizziness/Fainting yesno
On Warfarin yesno
Are you Pregnant? yesno
if so, what is your due date?

Are you currently taking any medications? yesno

Are you taking or have you taken any Bisphosphonate drugs? yesno

If YES please provide details

Have you had any of the following dental issues?

Does your jaw click or hurt? yesno
Do you feel you grind your teeth? yesno
Orthodontic Treatment? yesno
Do you wear a guard at night? yesno
Sensitivity to hot or cold? yesno
Have you had gum Disease? yesno
Do you smoke? yesno
Bad Breath? yesno
Bleeding Gums yesno
Pain on bitting hard? yesno
Food jamming between teeth? yesno
Problems flossing? yesno

Other Notes or Concerns you would like us to know about?

How long since your last dental visit?

How often do you have dental examinations?

Previous dental xrays were taken: Less than a year ago?Longer than a year ago?

Consent for Treatment

I hereby authorise the dentist or designated team to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I understand I can ask for a complete recital of any complications associated with treatment I may need. I agree to be responsible for payment of all sevices rendered on my behalf and on behalf of my dependents. I understand that payment is due at the end of service unless other arrangements have been made. I authorise that this information may be reviewed by team members of the dental practice.

Today's date:

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