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Adult Patient Medical History
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Title*
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Patients Name*
Date of Birth*
Address*
Email*
Contact number/s*
Are you currently on any medication*
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Are you under the care of a Medical Practitioner*
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Do you have any allergies*
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No
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General Dentist Name*
Dental Practice*
When was your last dental check-up*
Less then 6mths ago
6-12mths ago
12-24mths
More then 24mths
Medical History
Please tick if you have any of the following*
A heart disorder/Murmur
Asthma
Rheumatic Fever
Diabetes
Pregnant
Tonsils removed
Thyroid Problem
Hepatitis
Anxiety
Aids/related disease
Adenoids removed
Attention Deficit Disorder
Bleeding Disorder
Dental History
Please tick if you have any of the following*
Fluoride
Baby Teeth Extracted
Filling, Caps or Crowns
Root Canal Treatment
Permanent Teeth Extracted (including wisdom)
Chipped or Injured Teeth
Breathe predominantly through the mouth
Periodontal (gum) Disease
Teeth not Appeared
Suck/ed Thumb or Finger
Any other illness/disability not listed above: *
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Have you had any jaw pain or clicking *
Yes
No
Please list
Have you had any speech therapy *
Yes
No
Please list
Is there any Family dental traits *
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No
Please list
What is your main concern in seeking this appointment *
How did you hear about us *
Family
Friends
Newspaper
School Newsletter
Website
Google
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Dental referral
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Next of Kin
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Relationship to patient*
Address*
Email*
Contact number/s*
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Date*
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