Welcome to Beachside Complete Dental Care and Dental Implant Centre, so that we may provide you with the best possible care please complete all sides of this medical history form. All information is completely confidential.

    PATIENT INFORMATION


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    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
    In the event payment is not received in full, the person responsible for fees is responsible for recovery service fees.

    YesNo

    SelfOther




    Cancellations: 48hrs 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

    HospitalDental



    YesNo



    YesNo

    Who recommended our practice to you?

    Existing patient


    Beachside Dental WebsiteStaff MemberGoogle searchDentistPassing byDoctor

    MEDICAL HISTORY QUESTIONNAIRE

    To the best of your knowledge do you or have you suffered from the following? If possible, please provide approximate date of diagnosis.

    Please Tick

    Questions

    DETAILS

    NoYes

    High Blood Pressure

    NoYes

    Low Blood Pressure

    NoYes

    Osteoporosis medication or injections

    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

    Cancer

    NoYes

    Chemotherapy/Radiation Therapy

    NoYes

    Physical, sensory, or learning disabilities

    NoYes

    Stroke

    NoYes

    Arthritis

    NoYes

    Mental health issues

    NoYes

    Respiratory

    NoYes

    Back or neck problems

    NoYes

    Neurological (nerve problems)

    NoYes

    Digestive problems

    NoYes

    Lung disease

    NoYes

    Infection diseases

    NoYes

    Epilepsy

    NoYes

    Bone Disease / Disorder

    NoYes

    Tuberculosis

    NoYes

    Hormone Supplements

    NoYes

    Hearing impairment/difficulties

    NoYes

    Knee / Hip / Joint Replacement

    NoYes

    Intellectual difficulties

    NoYes

    Ladies, are you pregnant? If so, how many weeks?



    Do you smoke?

    NoYes


    Do you drink alcohol regularly?

    NoYes


    Do you have any allergies?

    NoYesMaybe

    Do you have any adverse reactions to drugs?

    NoYesMaybe

    Are you allergic to Penicillin?

    NoYesMaybe

    Are you allergic to latex?

    NoYesMaybe



    Medicines

    There are many medications that may impact upon your oral health or the treatment we plan for you. Please indicate any medications that you are currently taking or have taken recently (including natural therapies). Alternatively, a list from you GP can be attached.

    DENTAL HISTORY

    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

    Do your gums bleed when you clean your teeth?

    NoYes

    Do you suffer from bad breath?

    NoYes

    Are you interested in teeth whitening?

    NoYes

    Have you had previous gum problems?

    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*.