Confidential Patient Medical Form

CONFIDENTIAL PATIENT MEDICAL FORM

ALL INFORMATION IS KEPT PRIVATE AND CONFIDENTIAL

TITLE ___ __ SURNAME ______GIVEN NAME______

PREFERRED NAME______DATE OF BIRTH______MALE/FEMALE

ADDRESS______TOWN______POST CODE______

 HOME ______ MOBILE______ WORK______

*PLEASE TICK PREFERRED PHONE NUMBER FOR US TO CONTACT YOU

EMAIL ______OCCUPATION______

HEALTH FUND(Dental) ______VET AFFAIRS GOLD/WHITE(CIRCLE) VET AFFAIRS NO. ______

MEDICARE CARD NO. ______IRN EXPIRY______

PENSION CARD NO.______IRN EXPIRY ___

HEALTH CARE CARD NO.______IRN EXPIRY______

NEXT OF KIN/EMERGENCY CONTACT______

RELATIONSHIP ______EMERGENCY/ALTERNATE CONTACT NUMBER______

*PLEASE ENSURE EMERGENCY CONTACT NUMBER IS DIFFERENT TO THE PRIMARY CONTACT

YOUR MEDICAL PRACTICE______

DOCTOR’S NAME______PHONE NUMBER______

HOW DID YOU HEAR ABOUT OUR PRACTICE? ______

PLEASE BE AWARE, FEES MUST BE PAID ON THE DAY OF TREATMENT

PLEASE TURN OVER

MEDICAL HISTORY

PLEASE NOTE: YOU MUST ANSWER ALL QUESTIONSHONESTLY

ALL INFORMATION IS KEPT PRIVATE AND CONFIDENTIAL

MEDICAL CONDITION – CURRENT OR PASTYESNOMEDICATIONS/TREATMENT/DETAILS

High or Low blood pressure______

Diabetes______

Epilepsy/Stroke______

Asthma/hay fever/sinus______

Thyroid disorder______

Immune system disorder______

Mental illness/Depression/Anxiety______

Autism/other behavioural condition______

HIV______

Hepatitis A, B, or C______

Rheumatic fever______

Bleeding/blood disorders______

Dizziness/fainting______

Gastric disorder/reflux______

Cancer______

Pacemaker/heart surgery etc______

Other heart disorder/complaint______

Liver/kidney disorder______

Lung disorder/Tuberculosis______

Osteoporosis______

Any other condition not mentioned above?______

TREATMENT/MEDICATION/ALLERGIESYESNO

Have you had joint replacement, pins or plates in the last 6 months?

Have you ever had radiotherapy or chemotherapy?

Do you take blood thinning medication?

Do you take corticosteroids?

Do you take bisphosphonates?

Do you require antibiotics prior to dental treatment?

Do you take Viagra?

PLEASE LIST ANY OTHER MEDICATION NOT PREVIOUSLY MENTIONED

______

PLEASE LIST ALL ALLERGIES

______

ANY OTHER INFORMATIONTHAT MAY BE RELEVANT TO YOUR DENTAL TREATMENT?

______

OTHER RELEVANT INFORMATION

Do you smoke? Yes  No How many daily? ______

Are you pregnant? Yes No Due date______

Do you take any recreational drugs? Yes  No ______

Signature Date