Medical History Form | Future Dental

First Name: *

Last Name: *

Date of birth: *

Postal address: *

Postcode: *

Home phone: *

Work phone: *

Mobile phone: *

Email:

Residential address:

If different from postal address

Occupation:

Place of employment:

Emergency contact: *

Person to contact in the time of an emergency

Relation to emergency contact: *

Emergency contact phone number: *

Do you have private health dental insurance?: *

Yes

No

How did you find our phone number/address?:

Whom may we thank for referring you to our practice?:

Please list the main reasons for seeking care today: *

Do you have any allergies?:

Yes

No

e.g. Penicillin, aspirin or disinfectants

Are you pregnant?:

Yes

No

Do you bruise or bleed easily after injury?:

Yes

No

Have you ever experienced prolonged bleeding?:

Yes

No

Do you smoke cigarettes?:

Yes

No

Have you ever had a difficult tooth extraction?:

Yes

No

Have you taken asprin in the last 7 days?:

Yes

No

Have you had any of the following medical conditions?:

Tick any that apply

Please give details of all medications being taken:

Including over the counter medicines

Please give details of medical conditions:

Have you ever had any other serious illness?:

Yes

No

Have you been in hospital in the last two years?:

Yes

No

Have you ever had a blood transfusion?:

Yes

No

Name of medical doctor:

Phone number of medical doctor:

Are you under any medical treatment or currently taking any medication?:

Yes

No

HIV, AIDS and some types of hepatitis are transmissible by blood, saliva and bodily secretions. Do you think you might be in a high risk group?:

Yes

No

Are there any matters you would like to discuss with the dentist alone?:

Yes

No