Chermside Family Dental Welcome

Title *

Surname *

Given Names *

Date of Birth *

Address *

Suburb *

Post Code *

Email *

Phone *

In case of emergency call *

Their contact number *

I have confidential medical information that I do not wish to write down. I would prefer to speak to my dentist about this.

Do you normally require antibiotic cover before dental treatment? *

Yes
No

Have you had any abnormal reactions to local or general anaesthesia? *

Yes
No

Do you smoke? *

Yes
No

Are you being treated by a doctor at present? *

Yes
No

If yes, please supply details

Are you taking any medication at present? *

Yes
No

If yes, please list your medications

Females, are you currently pregnant?

Yes
No

Who is your medical practitioner?

Telephone

Do you have any allergies? *

Yes
No
Option 3

Please list any drugs or medicines you are allergic to

Please list any other known allergies

Diabetes *

Yes
No

Asthma *

Yes
No

Rheumatic fever *

Yes
No

Tuberculosis *

Yes
No

Steroid Therapy *

Yes
No

Bronchitis, emphysema or other lung diseases *

Yes
No

Stomach or digestive condition *

Yes
No

Anxiety, depression and other mental disorders *

Yes
No

High blood pressure *

Yes
No

Heart disease or heart complaints *

Yes
No

Stroke *

Yes
No

Excessive bleeding *

Yes
No

Kidney disease *

Yes
No

Hepatitis or other liver diseases *

Yes
No

Contact with blood borne viruses, e.g. HIV/AIDS *

Yes
No

Epilepsy *

Yes
No

Prosthetic implant *

Yes
No

Cardiac pacemaker *

Yes
No

Treatment for cancer *

Yes
No

Radiation therapy *

Yes
No

Thyroid disease *

Yes
No

Anaemia, leukaemia or other blood disorders *

Yes
No

Bone disease, including osteoporosis *

Yes
No

Sleep aponea *

Yes
No

Please list any other medical conditions:

Please list any concerns you have with your teeth or mouth:

Health fund: (if applicable)

07 3350 3530

Patient Registration

Personal Details

Medical details

DO YOU HAVE NOW, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS?