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)

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