Dental Patient Form Page 2
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1
2
3Dr Sharon Marinucci
Dr John Wills
Dr Ruth Mansell
Dina Jeffery
BDS / BSci Dent (Hons)
BDS
BDS / MJDF
Dental Therapist
Dr Ruth Drakes
Dr Margaret Kleinig
Dr Emma Codrington
Wendy Summerill
BDS
BDSc QLD
BMedSci / BDent
Dental Therapist
Dr Cathy Do
Dr Philippa McCarron
Dr David Armstrong
Bernadette Basset
BD
BDS
BDC MdSc
FRACDS
Dental Therapist
(Ortho)
(Ortho) PhD
Dr Devendra Rao
Dr Benjamin Mansell
Sue McDonald
Ms Susan Waldorf
BDS
BDS / MJDF
Dental Prosthetist
Oral Health Therapist
Dental Corporation Pty Ltd abn: 92 124 730 874
MEDICAL HISTORY
Are you taking any of the following medications
(please circle)
Warfarin (Coomadin/Marevan) - Aspirin (Astrix/Cartia) - Plavix - Iscover
Are you taking any other medications
(incl. dietary supplements)
If yes please provide details _____________________________________________________________
Are you taking any bisphosphonate medications or medications for osteoporosis, myltiple myeloma,
metastatic cancer or pagets disease
If yes please provide details _____________________________________________________________
Have you ever had an adverse reaction to local anaesthetics or other medications?
List here _____________________________________________________________________________
Females, are you pregnant? Yes / No
Have you ever smoked? Yes/ No
If yes, how many per day? ____________
When did you have your last cigarette? ____________________________________________________
Are you in a high risk category for AIDS/Hepatitis? Yes / No
Have you ever had or are currently su ering from any of the following?
(please circle)
Rheumatic Fever
Yes
No
Thyroid Problems
Yes
No
Heart Complaints
Yes
No
High Blood Pressure
Yes
No
Arti cial Joint
Yes
No
Diabetes
Yes
No
Cancer
Yes
No
Stroke
Yes
No
Bleeding
Yes
No
Asthma
Yes
No
Allergies
Yes
No
Hepatitis
Yes
No
HIV infection
Yes
No
Epilepsy
Yes
No
Radiotherapy
Yes
No
Infectious Diseases*
Yes
No
Yes
No
Osteoporosis
Yes
No
Other illnesses
*eg CJD, TB, Staph, etc
If yes to any of the above, please give details: ______________________________________________
If you have indicated a heart complaint above, please circle those that apply:
Heart Attack
Angina
Surgery
Pacemaker
Murmur
Valve Problem
Bypass
Do you play any sport? Yes / No
Is there anything else about your health you believe we should know about?
__________________________________________________________________________________________________
Initial _________________________
PO Box19
252 Harbour Drive
46 Bonville Street
1 Princess Street
Grafton NSW 2460
Coffs Harbour NSW 2450
Urunga NSW 2455
Macksville NSW 2447
p
(02) 6643 2225
p
(02) 6651 1350
p
(02) 6655 5800
p
(02) 6568 1335
f
(02) 6643 5544
f
(02) 6651 1973
f
(02) 6655 5801
f
(02) 6568 1222
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Parent category: Medical