Medical History Form

Medical History Form

Name *

First

Last

Gender *MALEFEMALEN/A

Martial StatusSingleMarriedDivorcedLegally SeparatedWidowedDe facto

Address *

Street Address *

Suburb *

State *

Postal *

Mobile Number *

(000) 000-000

Email *

Have you suffered recently from the following dental problems? Please tick the checkbox if YES.

• Anaemia
• Diabetes
• Cancer
• Excessive Bleeding
• Blood Pressure
• Arthritis
• Radiation Theory
• Blood Disease
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Stroke
• Osteoporosis
• Pacemaker
• Asthama
• Thyroid Problems
• Tuberculosis
• Artificial Joints
• Heart Disease/Murmur
• Rheumatic Fever
• Psychiatric care
• Kidney Disease
• Others

Doctor

Telephone Number

Have you had any other serious illness? *

• Yes
• No

If yes, please explain:

Are you taking any medicines or tablets regularly (including any over the counter medicines, vitamin supplements, or herbal remedies)?

• Yes
• No

If yes, please list:

Do you snore?

• Yes
• No
• Don't Know

If yes, have you had a sleep study or been diagnosed with sleep apnoea?

• Yes
• No

Do you suffer from any allergy? *

• Yes
• No

If yes, please explain

Are you a smoker?

• Yes
• No

If yes, how many years have you been smoking?

Are you pregnant?

• Yes
• No

If yes, how many weeks?

Next of Kin (in case of emergency):

Telephone Number

Consent of Services: By ticking the text box below and submitting button, you are agree with the following:

• This is to certify that I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic as indicated and I will assume responsibility for the fees associated with these procedures.
• I shall pay any legal costs, including solicitor and own costs, tracing costs and any collection commission incurred by PRODENTAL CLINIC as a result of my failure to pay any amounts due to PRODENTAL CLINIC.
• I have been advised that it is the policy of the PRODENTAL CLINIC to list any defaulting accounts with Equifax.

(if < 18 years of age) Parent/Guardian Details:

First and Last Name

Date

DD-MM-YYY

Submit