DENTISTS ON STARKEY MEDICAL HISTORY FORM
Please print a copy, fill it in and bring it with you to your next appointment with us. Thank you.
REGISTRATION
Date:
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: __________________
HOW DID YOU FIND US:
O Existing patient O Yellow Pages O Internet O Friend _______________________
O Other _____________________________
CONFIDENTIAL MEDICAL HISTORY
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?
Name:
Quantity:
For what reason:
CONFIDENTIAL MEDICAL HISTORY
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:
FOR DENTIST’S USE ONLY: MEDICAL HISTORY UPDATE
DATE
INITIAL
COMMENTS
DATE
INITIAL
COMMENTS
Name: Date:
CONFIDENTIAL DENTAL HISTORY
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?