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Medical History Form

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Contact Details
WORKING HOURS
MON – FRI
9.00 AM – 5.30 PM
SAT
9.00 AM – 1.00 PM
SUN
CLOSED

Medical History Form

Welcome To Our Practice!

Name *

Address

Suburb

Postcode

Phone No

Work

Mobile

Date Of Birth

Occupation

Parent/Guardian names if under the age of 16:

Are you in a Private Health Fund for Dental?

YesNo
If yes, which one?

Are you covered by Veterans Affairs?

YesNo
If yes, card number?

How did you find out about Our Practice?

AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther
Have you ever had or do you have any of the following? (Please tick)

High Blood Pressure

YesNo
Diabetes

YesNo
Heart Conditions or Heart Surgery

YesNo
Arthritis

YesNo
Excessive Bleeding

YesNo
Asthma or Bronchitis (Which one?)

YesNo
Rheumatic Fever

YesNo
HIV or Hepatitis A,B or C (Which one?)

YesNo
Hip/Knee Replacement (Which one?)

YesNo
Epilepsy

YesNo
Anxiety or Depression (Which one?)

YesNo
Hay Fever or Sinus

YesNo
Allergies

YesNo
Ladies, are you pregnant?

YesNo
Radiation therapy to the head or neck

YesNo
Treatment therapy for cancer

YesNo
Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:

Other serious injury or illness:

List any medication you are currently taking:

GP's Name and location:

Signature*

Date*

  • Opening Hours

    We are available 6 days a week
    Monday to Friday
    9:00 AM – 5:30PM
    Saturday
    9:00 AM – 1:00PM

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