Confidential Medical History Form
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1
2CONFIDENTIAL MEDICAL HISTORY FORM
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
Home Ph.: ____________________ Work: ________________________ Mobile: _____________________
Email: _____________________________________________________ DOB: ______________________
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Please check if you would not like to be a part of our online communications and email newsletter database. We send a
newsletter out quarterly.
Preferred Method of contact (please select):
Home☐
Work☐
Mobile☐
SMS☐
Any☐
Occupation: ___________________ Health Fund: ______________________________________________
Next of Kin: ____________________ Phone: ___________________________________________________
Person Responsible for fees (if not self): _______________________________________________________
Address: ________________________________________________________________________________
Have you had any of the following (please check the appropriate boxes):
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Heart Problems
Asthma
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High Blood Pressure
Sinus Troubles
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Low Blood Pressure
Liver/ Kidney Problems
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Anaemia/other blood disorders
Stomach Ulcers
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Stroke
Rheumatic Fever
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Tumours/ Cancer
Hepatitis
A
B
C
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Radiation Treatment
HIV/AIDS
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Artificial Joints
Allergy to Medications
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Circulatory Problems
Allergy to Anaesthetic
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Excessive Bleeding
Allergy to Penicillin
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Excessive Bruising
Allergy to Latex
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Diabetes
Epilepsy
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Do you require antibiotic therapy for any condition prior to undergoing dental treatment?
i.e.; existing heart murmur or artificial hips/ knees
Please list any drugs or medicines including fish oil and omega 3 that you are currently taking:
_______________________________________________________________________________________
_______________________________________________________________________________________
Doctor: _________________________________________________________________________________
Address: ________________________________________________________________________________
Yes ☐
No ☐ Due Date: _____________________________________
Ladies are you pregnant?
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Parent category: Medical