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New Patient / Medical History Form

Would you please be kind enough to answer all the questions below.

All information will be treated with complete professional confidentiality.

New Patient / Medical History Form

Full Name*
Date of Birth*

Day
Month
Year
Marital Status*
- Single
- Married
Email address*
Address*
Mobile Number*
Office Number
Home Phone Number
Best Phone Number for daytime contact*
Occupation*
In Case of Emergency Call (Name & Contact Number)*
Name of Private Insurance Fund*
How did you hear about us?*
How long has it been since your last dental exam?*
Are you happy with your smile?*
- Yes
- No
Would you like to talk to us about tooth whitening?*
- Yes
- No
How is Your General Health?*
- Excellent
- Good
- Fair
- Poor
Your Family Doctor's Name & Number*
Are you pregnant?*
- Yes
- No
If you are pregnant, when is your expected due date?
Do you smoke?*
- Yes
- No
Do you have any allegies? (e.g. Latex, Bickel, etc)*
- Yes
- No
If you have allergies, please provide details
Are you allergic to any medication? (including antibiotics)*
- Yes
- No
If you are taking any medication, please provide details
Are you taking any medication?*
- Yes
- No
If you are allergic to any medication, please provide details
Have you ever had Rheumatic Fever?*
- Yes
- No
Have you ever had Heart Murmur?*
- Yes
- No
Have you ever had Heart Disease Surgery?*
- Yes
- No
Have you ever had a Cardiac Pace Maker?*
- Yes
- No
Have you ever had High or Low Blood Pressure?*
- Yes
- No
Have you ever had Joint Replacement Surgery?*
- Yes
- No
Have you ever had Blood Disorders?*
- Yes
- No
Have you ever had Prolonged Bleeding condition?*
- Yes
- No
Have you ever had a Stroke?*
- Yes
- No
Have you ever had Epilepsy?*
- Yes
- No
Have you ever had Nervous System Disorder?*
- Yes
- No
Have you ever had Tuberculosis?*
- Yes
- No
Have you ever had Asthma?*
- Yes
- No
Have you ever had Sinus Trouble?*
- Yes
- No
Have you ever had Diabetes?*
- Yes
- No
Have you ever had Stomach Ulcers?*
- Yes
- No
Have you ever had Kidney Disease?*
- Yes
- No
Have you ever had Organ Transplant?*
- Yes
- No
Have you ever had Hepatitis?*
- Yes
- No
Have you ever had any Form of Cancer?*
- Yes
- No
Have you ever had Radiation Therapy?*
- Yes
- No
Have you ever had Bone Diseases/Osteoporosis?*
- Yes
- No
Have you ever had Bisphosphonate Therapy?*
- Yes
- No
Have you ever had Thyroid Disease?*
- Yes
- No
If you had any of the items liste about, please provide more details
Have you ever had HIV/AIDS?*
- Yes
- No
Are you particularly nervous about any dental treatment?*
- Yes
- No
Do you normally have injections for your dental treatment?*
- Yes
- No
How do you rate the overall condition of your mouth (1 - poor & 5 - excellent)?*
- 1
- 2
- 3
- 4
- 5
What are you expecting from today's visit?*
Would you like us to talk about Sedation Dentistry - Intravenous Sedation (IV)?
- Yes
- No
Would you like us to talk about Sedation Dentistry - General Anaesthetic (GA)?
- Yes
- No
Would you like us to talk about Sedation Dentistry - Inhalation Sedation (Happy Gas)?
- Yes
- No
Would you like us to talk about Sedation Dentistry - Oral Sedation?
- Yes
- No
Date*
Your Message
Name
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