Medical History Form - Sydney Holistic Dental Centre

Please note that any information provided will remain STRICTLY CONFIDENTIAL

Main Reason For Attending Our Dental Centre:

Comprehensive Oral Health Assessment
Pain
Headaches, neck aches or jaw pain
Bad breath
Snoring, sleep apnoea or poor sleep
Amalgam removal
Holistic approach to your health
Cosmetic Concerns
Consultation on root canal treatment
Dental Implants
Oral health maintenance
2nd Opinion

Other reason(s):

PATIENT INFORMATION

First Name**

Last Name**

Title (Mrs, Mr, Dr, etc.)

Date of birth (dd/mm/yyyy)**

Ph (home)

Ph (work)

Mobile**

Email**

Street Address

Suburb and Postcode

Occupation

Note: If patient is a minor, please note below the name of the parent or guardian completing this form.

First Name

Last Name

Title (Mrs, Mr, Dr, etc.)

Phone

DENTAL HISTORY

Please tick if you have had or are currently experiencing:

NB: Please let us know if cold sores are active as this is important for you and for us.

Do you experience headaches?

How often do you experience headaches?

One/week
One/month
Every day

Where do you experience headaches?

Temple
Front of head
Back of head
Around eyes

Do you experience neck aches?

How often do you experience neck aches?

One/week
One/month
Every day

Do you experience migraines?

How long has this been going on?

Do you experience jaw aches?

How often do you experience jaw aches?

One/week
One/month
Every day

Do you floss or clean in-between your teeth?

Are you happy with the appearance of your teeth?

Would you like an explanation about teeth whitening?

How long since your last dental visit?

Would you describe yourself as a relaxed patient?

Have you seen or are you aware of dental hygienists and/or oral health therapists?

Is there anything about your previous dental experiences you would like us know?

Do you have any specific requests?

SLEEP - Assessing the quality of your sleep:

Is it easy for you to fall asleep at night?

Do you wake up with a headache?

Do you wake up feeling refreshed?

Do you wake throughout the night?

Sleeping position:

Do you snore?

Does your partner snore?

Would you like information about our snoring appliance?

Are you likely to doze off or fall asleep in the following situations?

Sitting inactive in a public place
Sitting and talking to someone
In a car, while stopped in traffic
Sitting and reading
Watching TV
Relaxing after lunch without alcohol
None of these

MEDICAL HISTORY

Please tick if you currently have or have ever experienced any of the following medical conditions:

Do you have any other medical conditions?

Approximately when was your last medical check-up?

Are you currently seeing a health professional for any health problems?

Are you pregnant?

Are you trying to fall pregnant?

If you smoke, how many cigarettes a day?

If you drink coffee, how many a day?

If you drink soft drink, how many a day?

Are you taking any medications or supplements? (Please specify)

Are you allergic to anything? (Please specify)

OTHER DETAILS

How did you hear about us?

Existing Patient Name

Health Professional Name

Other Source

Reminder System:

We remind our patients of their appointments. How would you like us to remind you?

SMS
Mobile
Home phone
Work Phone
Email

Keep informed:

We keep you informed on what is new in the practice, services and health information via email.

I’d like to receive updates and be kept informed about information and news from the practice that may be relevant to my next visit.

Emergency Contact Details:

First Name

Surname

Title (Mrs, Mr, Dr, etc.)

Best contact number

Signature:

Date:

Comments

This field is for validation purposes and should be left unchanged.