Medical History Form Book an appointment

Medical history form

  Click here to print the Medical History Questionnaire

Dear Patient,

We ask you to provide the following pre-treatment information. The information we collect enables us to provide you with better care. Your privacy is important to us, so all information provided will be kept strictly confidential. Please kindly take the time to complete the below information prior to your appointment.

YOUR DETAILS

Title:
Given Name:
Preferred Name:
Surname:
Date of Birth:
Home Address:
Postal Code:
Mobile Phone:
Home Phone:
Email Address

BUSINESS CONTACT DETAILS

Your Occupation:
Business Name:
Business Address:
Postal Code

EMERGENCY CONTACT DETAILS

Name:
Contact No.:
Relationship to you:

DENTAL INFORMATION

What is the purpose of your visit:
Have you had any problems with past dental treatment?
If yes, please explain:
Do you belong to a Health Fund?
If Yes, Which one?
Membership No.:
Ref No.:
Are you a Veteran Affairs Card Holder?
Card No. :
How did you hear about this practice?
To whom shall we make your accounts payable?

I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment.

My preferred method of payment is:

CONFIDENTIAL HEALTH INFORMATION

Name of your general Medical Doctor:
Phone:
Address:
Are you being treated for a medical condition at present?
Are you taking any medications or supplements at present, both prescribed or over the counter? (Please List)

Do you have, or have you ever had, any of the following medical conditions?

High or low blood pressure
Leukaemia or cancer
Nervous or anxiety conditions
Heart ailments (valve problems, murmurs, pacemakers)
Radiation or chemotherapy
Eating disorders
Rheumatic fever
Organ or bone marrow transplants
Stomach or other bowel problems (ie. Reflux)
Excessive bleeding or blood disorders
Prosthetic implants
Hepatitis (A,B,C or other)
Asthma, chest of breathing problems
Thyroid problems
HIV or AIDS
Tuberculosis
Steroid therapy
Diabetes (Type I or Type II)
Bronchitis, emphysema or other lung diseases
Stroke
Epilepsy
Kidney disease
Other (Please Specify)
Do you have any allergies? (Penicillin, codeine, nickel, latex)
Please Specify:
Do you take any prescribed drugs, tablets, medicines, or creams?
Please Specify:
Have you ever been given medication for Osteoporosis or Osteoponeia?
Have you taken bisphosphonate medications? (Didronel, Fosamax, Aredia, Pamisol, Actonel, Zometa, Bonefos, Skelid or Bonviva)
How long have you been on the medication?
When did you last take them?
Have you even had any adverse reactions or allergic reactions to any treatment or medications?
Please Specify:
Do you have a heart murmur, or artificial heart valve?
Do you have any prosthetic body parts? (eg. Artificial hip shoulder or knee joints)
Please Specify:
Ladies, are you pregnant, undergoing fertility treatment or family planning?
If so, how many weeks?
Do you smoke?
If so, how many?

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