Medical History Form - Beachside Dental Clinic

Welcome, so that we may provide you with the best possible care please complete all fields of this medical history form. All information is completely confidential. No information is stored on this site for security purposes.

If you prefer to download and print the form, please download it here.

    PATIENT INFORMATION

    MRMASTERMRSMISSMSDR

    NoYes

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    Please note that our policy is to receive payment on the day of your treatment. We accept cash, eftpos, visa, mastercard and american express.

    YesNo

    Cancellations: 48 hrs notice of any cancellation is kindly required or a cancellation fee may be charged.

    Patients who have dental insurance: Item numbers are used as accurately as possible to describe the treatment received but cannot be claimed for anyone other than the person who received the treatment. The rebate is determined by your individual health insurance policy. Our surgery is not responsible for any concerns you may have regarding your health fund.

    YesNo

    Who recommended our practice to you?

    Existing patient

    DoctorStaff MemberDentistYellow Pages/sensisBeachside Dental WebsitePassing byGoogle searchCall ConnectFacebookLeader NewspaperSmooth FM Radio

    MEDICAL HISTORY QUESTIONNAIRE

    Please Tick

    Questions

    DETAILS

    NoYes

    High Blood Pressure

    NoYes

    Low Blood Pressure

    NoYes

    Heart Ailment or Heart Murmur

    NoYes

    Congenital heart Problem

    NoYes

    Heart Valve/Pin/Stent

    NoYes

    Pacemaker

    NoYes

    Rheumatic Fever

    NoYes

    Bleeding Disorder

    NoYes

    Diabetes

    NoYes

    Liver or Kidney Disease

    NoYes

    Hepatitis A / B / C / D / E

    NoYes

    HIV / AIDS

    NoYes

    Asthma

    NoYes

    Epilepsy

    NoYes

    Cancer

    NoYes

    Chemotherapy

    NoYes

    Bone Disease / Disorder

    NoYes

    Tuberculosis

    NoYes

    Hormone Supplements

    NoYes

    Knee / Hip / Joint Replacement

    NoYes

    Ladies, are you pregnant?

    Are you currently under any medical care?

    NoYes

    Are you allergic to Penicillin?

    NoYesMaybe

    Are you allergic to latex?

    NoYesMaybe

    Have you ever reacted badly to medication?

    NoYes

    Have you ever reacted badly to Dental Treatment?

    NoYes

    DENTAL HISTORY

    Do you smoke?

    NoYes

    Does your jaw click or hurt?

    NoYes

    Have your teeth chipped or worn down?

    NoYes

    Do you grind your teeth?

    NoYes

    Does food get stuck between your teeth?

    NoYes

    Have you had previous gum problems?

    NoYes

    Do your gums bleed when you clean your teeth?

    NoYes

    Do you suffer from bad breath?

    NoYes


    YesNo

    Please tick this box to confirm that you have read and understood our Privacy Policy, and consent to use of your health information in this way
    Yes, I've read the Privacy Policy*.