New Patient Medical History Step 1 of 2 50% Your DetailsName* Title Dr.MissMr.Mrs.Ms.Prof.Rev. Given Names Surname Email* Mobile*Gender Date Of Birth* Day Month Year Occupation* Home PhoneIncluding Area CodeWork PhoneIncluding Area CodeResidential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Postal AddressLeave blank if same as above Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred Contact Method* SMS Email Phone Mail Your Referral Details*How did you hear about our office? Google/Website Location/Business Signs Family or Friend Facebook Instagram Referee Name*Name of the referee so that we can thank them. Account DetailsPlease note that we ask for payment on the day of treatment. Eftpos and Hicaps are available.Account Responsibility*Who is responsible for settling the account? Private Health FundName of private health insurance if applicable Your Emergency Contact DetailsContact Name* First Last Contact Phone*Relationship Your Medical HistoryGP Name* GP Contact Details*Medical Conditions*Please select all conditions that are applicable to you, otherwise select “None of the above” at the bottom of the list. High Blood Pressure Low Blood Pressure Diabetes (circle Type I or II) Asthma/Breathing Problem Stomach/Bowel Problems (eg Ulcer) Tuberculosis Kidney Disease Thyroid or Endocrine Excessive Bleeding or Blood Disorder Epilepsy or Seizures Hepatitis AIDS/HIV Cancer or Tumor Radiation Treatment Bone Disorders or Disease Chemotherapy Rheumatoid or Arthritic Condition Acid Reflux Anaemia or Fainting Creutzfeldt-Jacob Disease Special Care or Learning Disability Mental Condition Pregnant Anticipating Pregnancy Smoker None of the above Medical Condition DetailsPlease list details for the conditions selected above.AllergiesPlease list any allergies, including medicines and products (e.g. Penicillin, Latex)MedicationsPlease list all medications that you are taking.Dental HistoryHow we can help you with your oral health concerns?Purpose of Visit*What is the purpose of your visit to us?Anxious or NervousDoes dental treatment make you nervous?Past Dental ExperienceNote down any problems that you have had with dental treatment in the past.Dental ConditionsSelect any dental conditions that are applicable to you Bleeding Gums or Bad Breath Trouble with Brushing or Flossing Discoloured Teeth or Fillings Chipped or Broken Teeth Worn Down Teeth Tooth Grinding or Clenching Jaw Clicking or Hurting Snoring or Sleep Apnoea Sensitivity to Hot/Cold Loose Teeth Missing Teeth/Gaps Ill-fitting Dentures Aesthetics or Appearance of Teeth Difficulty in Chewing/Jaw Opening Consent & AcknowledgementI have completed this Questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place ME at undue medical risk. I also give my permission for the practice to use the above contact details to send me an appointment and check-up reminders. All payments are required on the day of service. 24 hours notice is required for cancellation, if not fees may apply. By signing below I acknowledge that I have fully read and understood the policy.Consent* I agree to the above.SignatureDate* Day Month Year
