Please print a copy, fill it in and bring it with you to your next appointment with us. Thank you.



Last Name: _______________________      Mr/Mrs/Ms/Miss/Other:  ________              

First Names: _______________________________  Date of Birth: ______________                                         

I prefer to be called:__________________       Occupation: _________________              


Mailing Address:                                                                                                                                   

Suburb: _________________________________________   Post Code:                                  

Home Address:   _____________________________________________________________________

Suburb: __________________________________________  Post Code:                       

Home Telephone: ______________Mobile: ________________ Work:                                             


Emergency Contact Person: ________________________  Phone: __________________ 



O  Existing patient   O  Yellow Pages    O  Internet    O  Friend  _______________________  

O  Other      _____________________________                                                                    



The thoroughness of this medical history is designed for your safety.

Your complete answers will assist us in treating you with consideration for your individual needs.


The name of your General Medical Practitioner?                                                                                

Address & telephone number:                                                                                                                            

Date of last visit:                  For what reason:                                                                                                                             


The name of your Specialist Medical Practitioner?                                                                                

Address & telephone number                                                                                                                             

Date of last visit:                  For what reason:                                                                                                                             


Have you been hospitalised in the last five years?                                                                                   

For what reason:                                                                                                                                        


Do you have any allergies to:

  Drugs                       Anaesthesia                       Environment and Foods



                                                                                                                                                                                                                                                                                                                                Do you take, or have you ever taken, Biphosphonates (Fosamax, Actonel, Aredia, Pamisol, Zometa)?


Are you taking any medications/supplements at this time?



For what reason:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       



Do you have, or have you ever had any of the following conditions?

Liver disease _____

Joint problems _____

Malignancies _____

Hepatitis  _____

Joint Replacement _____

Radiation Treatment _____

Arthritis _____

Chemotherapy _____

Kidney disease _____

Neck/back problems _____

Stomach problem _____

Respiratory problems _____

Thyroid Problems _____

Asthma _____

Diabetes _____

Epilepsy/seizures _____

Emphysema     _____

Glaucoma _____

Psychiatric care _____

Tuberculosis _____

Immune deficiencies _____

Cold sores _____

Hormone Replacement _____

Currently Pregnant _____

Lactating _________


Please explain the details of any conditions ticked:                                                                                                                                                                                                                                                                                                                                                                                                                                                                         


Do you have, or have you ever had any of the following blood diseases?

Anaemia _____

Leukaemia _____

Infectious diseases ______________

Positive HIV test _____

Excessive bleeding  _____

Other _________________________


Please explain the details of any conditions ticked:                                                                                                                                                                                                                                                                                                        


Do you have, or have you ever had any of the following cardio vascular diseases?

Heart surgery _____

Rheumatic fever _____

Stroke _____

Cardiac pacemaker _____

Heart murmur _____

High blood pressure _____

Angina _____

Congenital heart _____

Low blood pressure _____

Heart attack _____

Mitral valve prolapse _____

Circulatory problems _____

Arteriosclerosis _____

Bypass _____

Other _____


Please explain the details of any conditions ticked:                                                                                                                                                                                                                                                                                                        


Have you ever been advised to take PROPHYLACTIC ANTIBIOTICS FOR DENTAL TREATMENT?                       

Name and prescription of the antibiotic:                       


Do you drink alcohol?             Drinks per week:                

Do you smoke?               Packs per week:             

If you have been a smoker, when did you quit?:                        


Recreational drugs, such as cocaine, marijuana, stimulants or depressants may have a fatal interaction with local anaesthetics or other common dental medications. Please describe the use of any drugs.                                               If you prefer, you may discuss this in complete confidence with the doctor.


Please list any other conditions this Practice should be made aware of:



Patient’s Signature:                                                     Date:                                                                                                         










Name:                         Date:            



What is your immediate dental concern?             




Are you having any discomfort at this time?             

O Teeth        O Jaw        O Gums        O Face        O Other             

How often do you usually visit the dentist?                         When was your last dental visit?             

What was done then?                          Date of your last Dental X-Ray?                

Do you fear having any dentistry done?  O YES  O NO            What?            

Do you find you need constant dental repairs?   O  YES    O  NO

Have you previously seen a Dental Specialist?   O  YES    O  NO             When?            

O Periodontist  O Oral Surgeon  O Prosthodontist  O Endodontist  O Orthodontist  O Other            

Name(s) of Specialist:             


Are you aware of any growths or swelling in your mouth?    O  YES    O  NO

On your cheeks, gums or lips, do you have frequent:

O Blisters      O Ulcers      O Lumps      O Pimples       O Swelling

Have you been told that you have gum problems?   O  YES    O  NO

Do your gums bleed when you brush?   O  YES    O  NO                   Floss?   O  YES    O  NO

Do you ever have any unpleasant taste?  O  YES    O  NO            When?            

Does food catch between your teeth?   O  YES    O  NO            Where?            


Have you ever had any injuries to your:   O  Neck      O Head      O Back     O Jaw       O Face

Do you have chronic headaches?   O  YES    O  NO            Neck aches?   O  YES    O  NO

Are you aware of your jaw:  O Clicking      O Popping      O Grinding      O Snapping    

Are your jaw muscles:   O Sore     O Tired     O Painful     O Locked      O Stiff

Do you clench your teeth?     O  YES    O  NO            When?            

Do you grind your teeth?    O  YES    O  NO            When?            


Do you have sensitivity to any of the following: O Hot     O Cold    O Sweet     O Sour 

O Pressure

Do you have any pain or soreness in the following areas?

O Eyes       O Ears      O Sinus       O Face       O Other             

In your mouth do you have any of the following?

O Burning      O Dryness     O Bleeding      O Itching       O Other             


Please indicate which items you use daily:   O Floss       O Interdens      O Proxy brush      

O Electric TB       O Hard TB    O Medium TB       O Soft TB     O Other             


Do you wear a removable denture?   O  YES    O  NO            O  Upper    O  Lower

Would you like to avoid wearing dentures?   O  YES    O  NO

Are you interested in finding out how to minimise your dental treatment needs?   O  YES    O  NO

Is there anything about your teeth or mouth you are uncomfortable with?            



Is there anything about your smile you would like to change?           




Is there any other condition you feel this practice should be made aware of?