Confidential Medical/dental History Form
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1
2Whole Health Dental Clinic
31 Dunstan Street
Clayton 3168
Dr Fred Karalis
BDSc. (Melb)
Tel: 9544 5993
Dr Shazia Sayed
B.D.S. ADC.Cert. GCOH (LaTrobe)
CONFIDENTIAL MEDICAL/DENTAL HISTORY FORM
It is important to know details about your medical history as these could affect the success of oral health care (dental treatment). The information you
provide is confidential and will be handled in accordance with our privacy policy which is shown on the second page of this form.
Last Name:
Title (eg Mr/Mrs/Ms):
First Name(s):
Date of birth:
Home Address:
Phone (Home):
Mobile:
Work:
Contact in case of emergency:
Phone:
Mobile:
I have confidential medical information that I wish not to write down. I would prefer to speak to a dentist about this
(please tick box)
NO
YES
DETAILS
Are you being treated by a doctor at present?
Are you taking any tablets or medicines (prescribed or over
the counter) at present?
Do you normally require antibiotic cover before dental
treatment?
Have you any abnormal reactions to local or general
anaesthesia?
Do you smoke?
Are you pregnant ( females only)
Health Fund?
Who is your medical practitioner?
Phone:
Please list any drugs or medicines you are allergic to:
Please list any other known allergies (including latex):
DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS?
(Please tick appropriate box(es)
NO
YES
NO
YES
NO
YES
Steroid Therapy
Kidney Disease
Prosthetic implant
eg artificial hip
Rheumatic Fever
Excessive Bleeding
Cardiac pacemaker
Epilepsy
Heart complaint
Stomach or digestive condition
Asthma
Nervous condition
Hepatitis or other liver disease
Diabetes
Tuberculosis
Contact with HIV/AIDS virus
Heart valve
Thyroid disease
Bronchitis, emphysema or other
disorder
lung diseases
Stroke
Heart murmur
Anaemia, leukaemia or other
blood diseases
Radiation therapy
High or low blood
Transplanted organ or marrow
pressure
Any other condition(s) (please list):
PLEASE LIST ANY PROBLEMS THAT YOU HAVE WITH YOUR TEETH OR MOUTH:
Referred By: Yellow Pages Street Sign Another patient/friend (Name)
I have read and accept the privacy policy on the second page of this form.
Office use only:
Signature: Patient/Parent/Guardian: _____________________________________________
Date:_______/________/_________
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