Medical History Form

Medical-history-Form
Contact Details
WORKING HOURS
MON – FRI
9.00 AM – 5.30 PM
SAT
9.00 AM – 1.00 PM
SUN
CLOSED

Medical History Form

Welcome To Our Practice!

Name *

Address

Suburb

Postcode

Phone No

Work

Mobile

Date Of Birth

Occupation

Parent/Guardian names if under the age of 16:

Are you in a Private Health Fund for Dental?

 Yes No
If yes, which one?

Are you covered by Veterans Affairs?

 Yes No
If yes, card number?

How did you find out about Our Practice?

 Advertising Family & friends Internet Walk-in/Seen the sign Yellow Pages Other
Have you ever had or do you have any of the following? (Please tick)

High Blood Pressure

 Yes No
Diabetes

 Yes No
Heart Conditions or Heart Surgery

 Yes No
Arthritis

 Yes No
Excessive Bleeding

 Yes No
Asthma or Bronchitis (Which one?)

 Yes No
Rheumatic Fever

 Yes No
HIV or Hepatitis A,B or C (Which one?)

 Yes No
Hip/Knee Replacement (Which one?)

 Yes No
Epilepsy

 Yes No
Anxiety or Depression (Which one?)

 Yes No
Hay Fever or Sinus

 Yes No
Allergies

 Yes No
Ladies, are you pregnant?

 Yes No
Radiation therapy to the head or neck

 Yes No
Treatment therapy for cancer

 Yes No
Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:

Other serious injury or illness:

List any medication you are currently taking:

GP's Name and location:

Signature*

Date*

  • Opening Hours

    We are available 6 days a week
    Monday to Friday
    9:00 AM – 5:30PM
    Saturday
    9:00 AM – 1:00PM
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