PATIENT HISTORY FORM

Health information is gathered for treatment purposes only. This information enables the provision of optimal dental care and helps in avoiding compromise of the patients general medical health.

Note: Dentists of Ivanhoe can provide the highest standard of care, please fill in this form carefully and throughly.

TitleDrMr.MrsMissMstrMsOther

Other Title

Surname

First Name

Preferred name

Date Of Birth:

Occupation

Phone (Mob)

Phone (Hm)

Phone (wk)

Home Address

Postcode

Emergency Contact

Relationship to patient

Address (if different to above)

Postcode

Medical Doctor

Contact No

Person responsible for account (must be completed if patient under 16) If as above please tick here

Name

Relationship to patient

Address (if different to above)

Postcode

Phone (Mob)

(Hm)

(Wk)

How did you hear of us? (Please Select following)

Other

Were you referred?

YesNo

If so, by who:

Medical Questions- Private and Confidential

Please take care to fill out this form completely. We rely on all your information to be able to provide you with appropriate dental services. Privacy Policy- We collect the information set out above in order to provide you with dental services. We will keep your information secure and confidential. If necessary, we may pass your information on to other health practitioners for a second opinion or referral purposes. We may also be required by law to provide your information to outside agencies. Our complete Privacy Policy is available at reception.

Past/Current medical conditions: (please tick)

hide

YesNo

Are you receiving any medical treatment at present?

YesNo

Have you ever had Botulinum Toxin (Botox/Dysport)?

YesNo

Have you ever had dermal filler injections?

YesNo

Have you had any serious or long standing illness?

YesNo

Have you ever been hospitalised?

YesNo

Are you currently pregnant or breastfeeding?

YesNo

Do you or have you ever smoked?

YesNo

How many ?

/day

Do you drink alcohol?

YesNo

Amount per day or week?

Have you ever had or are you currently receiving treatment for cancer?

YesNo

Details

Are you allergic to any medications/antibiotics/Latex or other?

YesNo

Details

Current medications (prescription, over the counter, herbal)

Please indicate if you have EVER had/have any of the following: (Please Tick)

Any heart complaint / treatment

YesNo

Rheumatic fever or heart valve surgery

YesNo

High or low blood pressure

YesNo

Blood disorders

YesNo

Anti-coagulant therapy

YesNo

Joint replacement surgery

YesNo

Osteoporosis or bone disease

YesNo

Epilepsy

YesNo

Diabetes

YesNo

HIV or other blood borne viruses

YesNo

Steroid therapy

YesNo

Sinus trouble

YesNo

Stroke

YesNo

Tuberculosis

YesNo

Any nervous system disorder

YesNo

Gastric ulcer / digestive conditions

YesNo

Asthma / bronchitis / lung conditions

YesNo

Radiation therapy / chemotherapy

YesNo

Thyroid disease

YesNo

Hepatitis A,B or C

YesNo

Jaundice or other liver diseases

YesNo

Transplanted organ or bone marrow

YesNo

Arthritis

YesNo

Depression / anxiety

YesNo

Kidney disease

YesNo

Bisphosphonate medications

YesNo

Please indicate if you have EVER had/have any of the following: (Please Tick)

hide

YesNo

When was your last dental examination and clean?

Are you currently experiencing pain or a specific dental problem?

YesNo

Details

Are you nervous, anxious or ever had a bad experience at a dental visit?

YesNo

Details

Are you happy with the appearance of your teeth and smile?

YesNo

Details

Do you have bleeding gums or have you ever been diagnosed with or treated for gum disease?

YesNo

How frequently do you brush your teeth?

Once/DayTwice/DayOther

How frequently do you floss or use brushes to clean between your teeth?

Is there anything you would like to talk to your dentist about that you are not comfortable writing on this form?

YesNo

Would you like to discuss or find out more about any of the following: (please tick)

Cosmetic appearance

Yes

Removal of wisdom teeth

Yes

Replacement of missing teeth

Yes

Crowns/Veneers

Yes

Teeth whitening

Yes

Root canal treatment

Yes

Bad breath

Yes

Dentures

Yes

Tooth grinding/Clenching

Yes

Implants

Yes

Replacement of silver (mercury) fillings

Yes

Invisalign/Orthodontics

Yes

Bleeding gums

Yes

Tooth decay

Yes

Tooth sensitivity

Yes

Tooth ache

Yes

I agree that the above is a true and accurate record. I understand that Dentists of Ivanhoe requires payment on the day of treatment. Any expenses, costs or disbursements incurred by Dentists of Ivanhoe in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I have read and agree with the privacy policy statement provided to me. PLEASE NOTE: This form will be electronically copied to your clinical record file and the original will be subsequently destroyed. By signing this document you agree to this process. This form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatments.

I have read and understood the PRIVACY CONSENT DOCUMENT and consent to the collection and use of my health information.

I have read and understood the PRIVACY CONSENT DOCUMENT and consent to the collection and use of my health information.

ON FUTURE VISITS ANY CHANGES TO THE ABOVE SHOULD BE ADVISED.

PATIENT HISTORY FORM

Medical Questions- Private and Confidential

Past/Current medical conditions: (please tick)

Please indicate if you have EVER had/have any of the following: (Please Tick)

Please indicate if you have EVER had/have any of the following: (Please Tick)

Would you like to discuss or find out more about any of the following: (please tick)

(03) 9499 9033

info@dentistsofivanhoe.com.au

4/8 Seddon St, Ivanhoe,
VIC 3079, Australia

Book Now

Location

Hours

PATIENT HISTORY FORM

Medical Questions- Private and Confidential

Past/Current medical conditions: (please tick)

Please indicate if you have EVER had/have any of the following: (Please Tick)

Please indicate if you have EVER had/have any of the following: (Please Tick)

Would you like to discuss or find out more about any of the following: (please tick)

(03) 9499 9033

info@dentistsofivanhoe.com.au

4/8 Seddon St, Ivanhoe,VIC 3079, Australia

Book Now

Location

Hours

4/8 Seddon St, Ivanhoe,
VIC 3079, Australia