Medical History Form Welcome To Our Practice! Name * MrMrsMsMissDrOther 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*
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