Patient Details

Name:
DOB:
Address:
Postcode:
Telephone:
Email:
Emergency Contact Name:
Emergency Contact Tel:

Your Referring Dentist

Name:
Address:
Postcode:
Tel:
Email:

Medical History

Your Medical History:

What is your current health: GoodFairPoor

Are you experiencing any pain or discomfort at this time? YesNo

Please indicate on a scale of 1-5 the level of pain you are experiencing:
1 (Mild)2345 (Extreme)

Please select any of the following you have had in the past or at present:
Heart ConditionHeart MurmurArtificial Heart ValveHigh Blood PressureRheumatic FeverBlood TransfusionLung DiseaseAsthma or Hay FeverKidney TroubleDiabetesThyroid DiseaseHepatitis or Liver DiseaseCancer or TumourRadiation/ChemotherapySTDsEpilepsy or SeizuresArtificial JointHIV Infection

Do you have any health issues not listed above? YesNo
If yes, please explain:

Are you presently taking any medicine or drugs? YesNo
If yes, please list:

Are you allergic to any medicine, drug, or other substance? YesNo
If yes, please list:

Have you ever been hospitalised or had surgery? YesNo

Have you ever had a reaction to local anesthetic? YesNo

Have you ever had prolonged or unusual bleeding? YesNo

Have you ever had illness following dental treatment? YesNo

Have you ever had an injury or trauma to your face or jaw? YesNo

Do you smoke or use smokeless tobacco? YesNo

Are you nervous or concerned about having dental work done? YesNo

Women: Are you pregnant now? YesNo
If so, when is the due date:

To the best of my knowledge, all of the preceding answers are true and correct. If I have any change in my health, or if my medications change, I will inform the dentist at the next appointment.

Human Verification

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