First Name(required) Surname Name(required) Preferred Name Address(required) Phone(required) Email(required) Date of Birth(required) Health Insurance Health Fund / Membership No / Series No Emergency Contact / Person Responsible (if more than one person, please let us know) Name Relationship Address Phone Email Person Completing Form (if different from above) Name Relationship Address Phone Email Medical History Questionnaire (please answer fully or discuss with dentist) Reason for Visit(required) Are you receiving any medical treatment presently? No Yes Details Have you had any serious or chronic illnesses? No Yes Details Have you ever been hospitalised? No Yes Details Do you have a disability? No Yes Details Do you have a mental illness? No Yes Details Do you have dental fear/phobia or related anxiety? No Yes Details Can you sit to stand? No Yes Details Can you weight bear? No Yes Details Wheelchair user No Yes Details: Manual/Motorised/Width(cm) Patient lifter required? No Yes Details Pregnant No Yes Due date Check all that apply: Stroke Heart problem/treatment Pacemaker Blood disorders High blood pressure Anti-coagulant medications Liver disease/Hepatitis/HIV Cancer treatment Osteoporosis/low bone density Transplanted organ/bone marrow Epilepsy Gastrointestinal disorder Asthma/lung conditions Diabetes Thyroid disorder Dysphagia/swallowing disorder Rheumatic fever Hearing, vision or speech problems Thickened fluids/soft diet Smoker Other Details Please list current medications below: (including vitamin supplements, herbal remedies, and injections) Have you ever had any tablets &/or injections for bones, or to prevent fractured bones? No Yes Which date did the injections/tablets commence? Allergies: (drugs, foods, etc.) If the dentist is running late, is this going to be an issue? No Yes Would a social story for the dental clinic be useful? No Yes Thank you for your trust in us. We will update you as to the progress of the new patient form. Submit Δ