• Suite 1, 850 Port Rd, Woodville SA
  • |
  • Call 08 7007 6339

Medical History Form
(New Patient)

    Your Personal Details:

    Gender:

    MaleFemale

    Title:

    Date of Birth:

    First Name:

    Preferred Name:

    Surname:

    Postal Address:

    Postcode:

    Mobile:

    Home:

    Work:

    Email:

    Occupation:

    Nationality:

    Would you like to be added to our mailing list: YesNo

    Name of Health Fund:

    Your I.D. No.:

    Best confirmation method for appointment (please check): SMSTelephoneEmail

    Person to contact in case of emergency:

    Relationship:

    Phone Number:

    How did you hear about us?

    FlyerOur WebsiteCinema AdverstisingYellow PagesHealth FundDriving Past

    Referred By (Who?)

    Information about your Medical/Dental History:

    When was your last dental treatment approximately?

    Last Dental Cleaning?

    Do you feel nervous about your dental treatment?

    GP Name:

    Phone No:

    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:

    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

    Cancer:

    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: