Medical History Form (Existing Patient) Your Personal Details: Gender: MaleFemale Title: Date of Birth: First Name: Preferred Name: Surname: Postal Address: Suburb: Postcode: Mobile #: Home #: Work #: Email Address: Occupation: Nationality: Would you like to be added to our mailing list: YesNo Name of Health Fund: Reference No.: Best confirmation method for appointment (please check): SMSTelephoneEmail Person to contact in case of emergency: Relationship: Phone Number: Information about your Medical/Dental History: GP Name: Phone #: Are you currently undergoing any medical treatment or had any surgery within the last 12 months? YesNo Are taking any medication, drugs or pills now? YesNo If yes, name medication and dosage: Are you taking any Biphosphonate Medications? Do you have any allergies? Please indicate below if you have had, or have at present any of the following: Females: Are you pregnant? YesNo Breast Feeding? YesNo Crohn's Disease: YesNo Smoker: YesNo Have / Having Botox: YesNo Heart Disease/Attact/Surgery: YesNo Heart Pacemaker: YesNo Artificial Heart Valve: YesNo Sjrogren's Syndrome: YesNo Join Replacement (Hip, Knee, etc.): YesNo Join Replacement Date: Bone Disease: YesNo Cance: YesNo Chemotheraphy/Radiation: YesNo Asthma: YesNo Fainting/Dizzy Spells: YesNo Epilepsy: YesNo Sinus/Hay Fever: YesNo Rheumatic Fever: YesNo Stomach Ulcers: YesNo Thyroid Problems: YesNo Diabetes: YesNo Stroke: YesNo Tuberculosis: YesNo Haemophilia: YesNo Emphysema/Chronic Cough: YesNo HIV / AIDS: YesNo Blood Pressure (High / Low): YesNo Latex Sensitivity: YesNo CJD: YesNo Osteoporosis: YesNo Arthritis: YesNo Rheumatoid: YesNo Hepatitis A/B/C: YesNo Other: We request and expect payment at the time treatment. For your convenience we accept cash, cheques, eftpos, all major credit cards. Also note that you are responsible for any costs incurred by our practice for recovery of outstanding payments. I understand that payment of the account is my responsibility, and that my Health Fund (if any) will not cover the full amount. I understand to pay any expenses incurred or to be incurred in the collection of any overdue portion of this account. Patient / Guardian Signature (Print Name): Date: