Refreshdental.com.au

CONFIDENTIAL INFORMATION:

Surname: ____________________________ First Name: __________________________ Date of Birth: _________________________ Home Address: ____________________________________________________________ ____________________________________________________________ Postal Address: ____________________________________________________________ Home Ph: __________________________________ Work Ph: _____________________________________ Mobile: _____________________________________ Email: ________________________________________ Your preferred method of contact: Email /Home Ph / Work Ph / Mobile Occupation: _______________________________________________________________ Employer:_________________________________________________________________ Emergency Contact: Name: ______________________________________Phone:_______________________
Private Health Fund: Yes / No; if yes, which fund? __________________________________________
How did you discover our Practice? ___________________________________________________________
CONFIDENTIAL MEDICAL HISTORY
Do you currently have, or have you ever been treated for any of the following conditions?
High or Low Blood Pressure (please circle) Heart Complaint or Surgery eg Bypass Operation Confirmed/Suspected contact with HIV/AIDS Virus Prosthetic Implant eg. Prosthetic Hip or Knee Bronchitis. Emphysema or other Lung Disease Name of Medical Practitioner: _________________________________________________________________ Do you have or have you ever had bone disease? ____________________________________________ (eg Osteoporosis, Paget’s Disease, Multiple Myeloma, Cancer which spread to bones) Are you taking or have you taken in the past Bisphosphonate medications? ________________
(eg Alendronate,Risedronate,Pmidronate,Zoledronate,Tiludronate,Etidronate,Clodronate,Fosamax,Actonel,Zometa,Aredia,Pamisol) ● When was your last dental visit? _____________________________________________________________ ● If yes, please list: _____________________________________________________________________________ ● Do you Smoke? _____________________________________ Yes / No ● Are you currently receiving any medical treatment? ● If yes, please advise: _______________________________________________________________________ ● Are you currently taking any medications? ● If yes, please list: _____________________________________________________________________________ ● Have you had an unfavourable reaction to local anaesthetics? Yes / No ● Have you ever had facial injectables?  If yes, please circle: Botox Dysport Dermal Filler  For female patients, are you pregnant? All information will be treated with complete professional confidentiality
Please tick the appropriate concerns
What concerns do you have?

Toothache
Sensitive Teeth (Hot / Cold)
Bleeding Gums
Loosening Teeth
Missing Teeth
Unsatisfactory Denture
Rapidly Decaying Teeth
Lost Filling - Cavity
Grinding / Clenching of Teeth
Worn / Broken Teeth
Pain in Face or Jaw Joints
Sounds (clicking) from Jaws
Difficulty / Discomfort when chewing
Appearance of Teeth
Other (please give details) _________________________________________________________________________________
Do you consent to sharing necessary records with dental specialists? Yes / No
Signature: ____________________________________ Date: _______________________
We request and expect payment at the time of treatment.
For your convenience we accept Cash, Cheque, Eftpos, Visa, MasterCard and Amex. In order to avoid a broken / failure to attend appointment fee, we require 24 hours notice to reschedule
an appointment. By signing this form you agree to these terms and conditions.
Dentist Signature: Date:

Source: http://www.refreshdental.com.au/wp-content/uploads/2014/01/refresh-dental-new-patient-medical-history.pdf