Medical History Form Home Medical History Form "*" indicates required fields Step 1 of 3 33% Title* Mr Mrs Ms Miss Master Dr Name* First Name Last Name Address* Street Address Suburb State Postcode Home Phone*Work Phone* Mobile*Email* Occupation* Date of Birth* DD slash MM slash YYYY Parent / Guardian names if under the of 16* Are you in a Private Health Fund for Dental?* Yes No Which one? (Dental Health Fund)* Are you covered by Veterans Affairs?* Yes No If yes, card number?* How did you find out about Our Practice?* Advertising Family & Friends Internet Walk-in / Seen the sign Yellow Pages Other Have you ever had or do you have any of the following? (Please tick)High Blood Pressure* Yes No Diabetes* Yes No Heart Conditions or Heart Surgery* Yes No Arthritis* Yes No Excessive Bleeding* Yes No Asthma or Bronchitis* Yes No Which one? (Asthma or Bronchitis)* Rheumatic Fever* Yes No HIV or Hepatitis A,B or C* Yes No Which one? (HIV or Hepatitis A,B or C)* Hip / Knee Replacement* Yes No Which one? (Hip / Knee Replacement)* Epilepsy* Yes No Anxiety or Depression* Yes No Which one? (Anxiety or Depression)* Hay Fever or Sinus* Yes No Which one? (Hay Fever or Sinus)* Allergies* Yes No Which one? (Allergies)* Ladies, are you pregnant?* Yes No Radiation therapy to the head or neck* Yes No Treatment therapy for cancer* Yes No Do you get headaches?* Yes No Do you breathe through your mouth?* Yes No Do you clench or grind your teeth?* Yes No Do you snore?* Yes No Do you feel refreshed in the morning when you wake up?* Yes No Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:*Other serious injury or illness:*List any medication you are currently taking:*GP’s Name and location:*Signature*Signature Date DD slash MM slash YYYY CAPTCHA
