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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