Medical History Form

PATIENT INFORMATION

 Mr Mrs Miss Ms.
Surname:
Given Names:
Address:
Suburb:
State:
Post Code:
Home Phone:
Work Phone:
Mobile:

INSURANCE INFORMATION

Health Fund:
Membership No:
Series No:
Are you a Veteran Affairs Card Holder?
 Yes No
Drivers License No.:
Are you a Seniors Card Holder?
 Yes No
Card No.:
Name Of Your Doctor/G.P.:
How did you hear about this practice?
 Family/Friend Local Paper Passing By Yellow Pages
Other:

MEDICAL AND DENTAL HISTORY

Have you ever had heart problems?  Yes No
Have you ever had high blood pressure?  Yes No
Have you ever had a blood transfusion?  Yes No
Have you ever had Rheumatic Fever, Diabetes, Hyperthyroidism, Asthma, Glaucoma, Nervous Disorders, Anaemia, Arthritis?  Yes No
Have you ever had any other serious illness?  Yes No
Are you currently under medical treatment  Yes No
Are you taking any drugs or medication?  Yes No
Have you any known allergies to drugs (especially Penicillin) medicines, antiseptics, iodine?  Yes No
Do you suffer from, or have any reason to suspect you may have Hepatitis, A.I.D.S., or any other infectious disease?  Yes No
Have you ever experienced prolonged bleeding?  Yes No
(Women) If pregnant, how many months?  Yes No
Is there anything that we should know about that you would like to discuss privately and confidentially with the dentist?  Yes No