Medical History Questionnaire Form - Dental Care Centre
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1
2Medical History Questionnaire
Title Dr / Mr / Mrs / Miss / Ms/ Other
Surname _________________________________ First name ________________________ Date of birth ___/___/ _____
Preferred name _______________________________________________________________________________________
Home address ________________________________________________________________________________________
___________________________________________________________________________ Postcode ________________
Postal address ______________________________________________________________ Postcode ________________
Phone (Mob) ______________________________ (Hm) ____________________________ (Wk) ____________________
Email _______________________________________________________________________________________________
Health fund for dental cover _________________ Membership No. ___________________ Patient ID. ________________
Medicare Card No. _____________________________________ Veterans’ Affairs Card No. _________________________
Occupation __________________________________________
Emergency contact ________________________ Relationship to patient ______________ Contact No. ______________
o
Person responsible for account (must be completed if patient under 16, if same as above please tick here
)
Name ___________________________________ Relationship to patient ________________________________________
Address ___________________________________________________________________ Postcode ________________
Phone (Mob) ______________________________ (Hm) ____________________________ (Wk) ____________________
If third party, insurance company/employer responsible for account ______________________________________________
Medical Questionnaire – Private and Confidential
Please answer these questions fully or discuss them with your dentist. Information about your medical history is for your dentist’s use only.
Past/Current medical conditions:
o
o
Are you receiving any medical treatment at present Y
N
Details _______________________________________
o
o
Have you had any serious or long standing illness Y
N
Details _______________________________________
o
o
Have you ever been hospitalised
Y
N
Details _______________________________________
Please indicate if you have EVER had any of the following:
o
o
o
o
Any heart complaint/treatment
Y
N
Tuberculosis
Y
N
o
o
o
o
Rheumatic fever or heart valve surgery
Y
N
Any nervous system disorder
Y
N
o
o
o
o
High or low blood pressure
Y
N
Gastric ulcer
Y
N
o
o
o
o
Blood Disorders
Y
N
Asthma/Bronchitis /lung conditions
Y
N
o
o
o
o
Anti-coagulant therapy
Y
N
Radiation therapy/chemotherapy
Y
N
o
o
o
o
Joint replacement surgery
Y
N
Thyroid disease
Y
N
o
o
o
o
Osteoporosis or low bone density
Y
N
Hepatitis, jaundice or liver disease
Y
N
o
o
o
o
Epilepsy
Y
N
Treatment for any form of Cancer
Y
N
o
o
o
o
Diabetes
Y
N
Transplanted organ or bone marrow
Y
N
o
o
o
o
HIV
Y
N
Pregnant (when due)
Y
N
Other
o
o
o
Do you smoke Y
N
Social
Current medications (prescription, over the counter, herbal) ___________________________________________________
_____________________________________________________________________________________________________
Allergies Nil known
o
o
Yes
- Details ________________________________________________________________
Medical practitioner ____________________________________ Suburb ________________________________________
I agree that the above is a true and accurate record. I understand that this nib Dental Care Centre is owned and operated by Pacific Smiles Group Limited
abn 42 103 087 449. Payment on the day of treatment is required. Any expenses, costs or disbursements incurred by the nib Dental Care Centre in
recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge
that failure to attend any appointment without notice may also result in a deposit requirement prior to future appointments being scheduled. I have read and
agree with the privacy statement on the back of this document.
PLEASE NOTE: The medical history form will be electronically copied to your clinical record file and the original will be subsequently destroyed. By
signing this document you agree to this process. This form is a guide only and you should discuss any relevant matters with your dentist prior to the
commencement of any dental treatments.
o
o
Do you consent to the disclosure by Pacific Smiles Group to nib Health Funds details of your medical history? Y
N
Signature _____________________________________________________________________________________ Date ____ / ____ / ______
OFFICE USE ONLY.
Form checked by ___________________ Data keyed by ________________ Keying checked by _________________ Form scanned by ______________________
IMPORTANT - PLEASE READ PRIVACY STATEMENT ON BACK OF THIS FORM
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