Medical history form

Next open: Mon 13th, 9am Closed

Use this form to outline your medical history to us. We use this information to make informed dental care decisions about you.

The form is submitted securely and your information is stored confidentially. Your information is only shared to other medical professionals if you give permission.

Instructions

Personal Details

Title *

First names *

Preferred name

If you prefer to be called something other than your first given name listed above

Surname *

Gender *

Female

Male

Date of Birth *

Parent/Guardian

Occupation

School name (students only)

Contact Details

Address *

Home phone

Cellphone

Work phone

Email address *

General Medical

Regular doctor *

Are you being treated for any health related conditions now? *

Yes

Are you taking any tablets, capsules, medicine or drugs now? *

Yes

Please list any medications you are currently taking.

In the last six months, have you taken any tablets, capsules, medicine or drugs? *

Yes

Is it possible you are pregnant?

Yes

How many weeks?

Do you smoke or vape? *

Yes

How much per day?

Medical Conditions

Have you ever had any of the following?

Cardiovascular

Respiratory

Asthma *

Yes

Chest & lung disease *

Yes

Sinus/hay fever *

Yes

Other

Medical History

Have you ever had any allergies to medicines or other substances (such as Latex)? *

Yes

Please list any allergies you've had.

Do you have an artificial or prosthetic joint? *

Yes

When was surgery?

Are you taking or have you taken in the last 10 years Bisphosphonate medication (treatment for osteoporosis / multiple myeloma / bone disease)? *

Yes

Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time? *

Yes

Have you ever had contact with:

HIV virus? *

Yes

Hepatitis B virus? *

Yes

Hepatitis C virus? *

Yes

Have you ever had an unfavourable reaction to an anaesthetic? *

Yes

Are there any other health matters you need to talk to the dentist about?

Dental

Do you consent to the use of amalgam restoration in posterior teeth? *

Yes

Is there anything you are unhappy about with your teeth / smile? *

Yes

What are you unhappy about?

Do you have any concerns / questions regarding dentistry? *

Yes

What are your concerns?

Are you nervous or worried regarding any aspects of dental treatment? *

Yes

Agreement

How did you hear about us?

Friend or word of mouth

Dentist referral

Yellow Pages

Online search (Google etc.)

Social media

Other

Mission Statement

Our aim at QE2 Dental is to provide excellent dental care and service in a friendly, professional environment. For any reason if you feel that you have not received care and treatment to a high level then please inform us so we can do something about it.

Payment

Payment is required at the time of treatment unless prior alternatives have been arranged. If the account is unpaid after 28 days, the outstanding balance will be forwarded to a professional debt collection agency. Any further expenses incurred by this are your responsibility.

Declaration

Notice

We will ask you to sign the declaration on our premises.

Patients under 16 years need to have the declaration signed by a parent or guardian.

Before starting

You will need this information handy before completing the form:

your usual doctor's name and contact details
records or memory of any medical procedures you have had, diseases you have, allergies etc etc.

If you prefer to print out a form, download the PDF in the panel below. Then you can post, fax, or bring the completed form to our office.

Form download

First page of Confidential General and Health Questionnaire

Confidential General and Health Questionnaire (PDF, 117.5KB)

Print this form out, fill it in, and bring it in for us if you prefer.