Suite 108, 24-30 Springfield Avenue, Potts Point NSW 2011

Medical History Form

    Prefix:
    MrMrsMsDr
    DOB:
    Age:
    Sex:
    MaleFemale

    How did you find us?: GoogleWebsiteFriend/FamilyStreet Sign
    Who can we thank for your referral?


    If you don't know please put NA

    If you don't know please put NA
    Are you currently under physician care?
    YesNo

    Are you currently taking any medication (including supplements and vitamins)?
    YesNo
    If yes, list medications and reasons for taking and indicate if you take it in the AM or PM:


    Do you have or have you had any of the following conditions?:

    Do you take any blood thinners
    NoYes
    Has your doctor stated that you need to pre-medicate with antibiotics before dental visits?
    NoYes
    Artificial / Damaged heart valves?
    NoYes
    Congenital heart defect?
    NoYes
    Prosthetic joint?
    NoYes
    History of heart attack? Angina? Chest pain on exertion? Pacemaker?
    NoYes
    High blood pressure? Do your ankles swell? Low blood pressure / dizziness?
    NoYes
    Sinus problems?
    NoYes
    Asthma? Other lung/breathing problems?
    NoYes
    Hepatitis, jaundice, other liver dysfunction?
    NoYes
    HIV?
    NoYes
    Sexually-transmitted disease?
    NoYes
    Thyroid problems?
    NoYes
    Arthritis? Swollen joints?
    NoYes
    Tuberculosis?
    NoYes
    Persistent cough that products blood?
    NoYes
    Stomach ulcers or other gastrointestinal problem?
    NoYes
    Kidney problems?
    NoYes
    Epilepsy or seizures?
    NoYes
    Cancer?
    NoYes
    Diabetes or high glucose?
    NoYes
    Psychiatric care?
    NoYes
    Low immune function?
    NoYes
    Bleeding disorders?
    NoYes
    Are you wearing contact lenses?
    NoYes
    Do you have osteoporosis or osteopenia?
    NoYes
    Do you smoke or use other forms of tobacco?
    NoYes
    Our office offers IV Sedation (Twilight Sleep). Would you like to discuss this as an option?
    NoYes
    Have you had any general surgeries?
    NoYes
    Do you take or have you ever taken any bisphosphonate (i.e. Fosamax, Actonel, Boniva, etc)
    NoYes
    When was your last dental cleaning?
    How often do you have cleanings?
    Have you had any serious problems with dental treatment?
    NoYes
    Do you have any medical disease or condition that is not listed?
    NoYes
    If you answered Yes to any of the above questions, please provide a brief history with relevant dates:

    Do you have an allergy to or have you had a bad reaction to:

    Are there any medications you cannot or prefer not to take?
    NoYes
    Local anesthetics (i.e. Novocain)
    NoYes
    General anesthetics/sedation medication
    NoYes
    Antibiotics
    NoYes
    Sulfite (red wine)
    NoYes
    Aspirin
    NoYes
    Codeine or other narcotics
    NoYes
    Do you have any medical disease or condition that is not listed?

    Women

    Are you, or do you think that you might be pregnant?
    NoYes
    Are you nursing?
    NoYes
    Do you take birth control pills?
    NoYes
    Do you have problems with your menstrual period?
    NoYes

    Men

    Do you take Viagra, Cialis or Levitra?
    NoYes

    Disclaimer

    I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.
    Signature of Patient or Patient's Representative
    Date
    Relationship to Patient (If not signed by the Patient)

    BOOK APPOINTMENT