Online Medical History

Welcome! It is important to know details about your medical history as these could affect the success of your dental treatment and how we can provide this treatment safely for you. To provide you with the best possible care, please complete ALL SECTIONS of this form. The information you provide is confidential and will be handled in accordance with our privacy policy.

If you would like to fill a printable copy of this form to bring in, please click here.

General Patient Information

Full Name*

Title Given Names Surname

Date of Birth*

Home Address*

Street Address City State Postcode

Home Phone*

If you don't have a home phone, please enter your main contact phone number.

Email*

Contact Email

Mobile Number

Work Phone

How did you find us?

Friend or Family Member's Name

Do You Have A Health Fund?*

Yes
No

⚠️ Please remember to bring your health fund card to your appointment. We are unable to process claims without the physical card being present at the time of your appointment. ⚠️

Private Health Fund Name

Health Fund Members Number

Dental Information

To ensure we have an accurate background to your existing and previous dental health, please indicate if you have or have not had any of the following diseases or problems.

Are you currently experiencing dental pain or discomfort?*

Yes
No

Do your gums bleed when you brush or floss?*

Yes
No

Are any of your teeth sensitive to cold, hot, sweet or pressure?*

Yes
No

Does food or floss catch between any of your teeth?*

Yes
No

Have you had any of the following?*

None
Periodontal (gum) treatments?
Orthodontic (braces) treatments?
Serious injury to your head or mouth?

Do you have any of the following?*

How long since your last dental visit?*

Overall, how do you rate your dental health?*

Were there any other specific dental concerns you have?

Medical Information

To ensure your dental treatment remains safe, please indicate if you have or have not had any of the following diseases or problems.

Are you being treated by a doctor at present*

Yes
No

Who is your medical practitioner?*

Please type "None" it you don't have a current medical practitioner

Medical Practitioner's Phone Number

Have you been hospitalised in the last 12 months?*

Yes
No

What was the illness or medical condition you were hospitalised for?

Are you pregnant?*

Yes
No
Not Applicable

Women only

Number of weeks

Are you nursing?

Yes
No
Not Applicable

Women Only

Medications & Other Products/Substances

Has a doctor or previous dentist recommended that you routinely take antibiotics prior to your dental treatment?*

Yes
No

Are you currently or have recently taken any prescription or over the counter medicine(s)?*

Yes
No

If yes, click "Yes" and please list all or upload list of medications

List of currently or recently taken medications

Medication List File Upload

Drop files here or

Accepted file types: jpg, bmp, png, pdf, doc, docx, Max. file size: 128 MB.

If you have a scanned medication list, you can upload it here.

Are you currently or have you taken any medications for osteoporosis or any other bone disease?*

Yes
No

Are you currently taking any medication or undergoing any treatment for cancer?*

Yes
No

Are you currently taking any medication which causes you to bleed more than usual (including Asprin)?*

Yes
No

Do you smoke or vape?*

Smoke
Vape
Smoke and Vape
No

How many a day?*

How many alcoholic beverages do you have per week?*

Medical Conditions and Allergies

Heart or Circulatory Conditions*

Lung / Respiratory Conditions*

Blood Related Conditions*

None
Excessive Bleeding
Contact with HIV, Hepatitis B or Hepatitis C
Anaemia, leukaemia or other blood diseases

Other Conditions*

Allergies*

Other Allergies

Do you have any disease, condition or problem not listed above that you think we should know about?

Please list if any

I Understand:*

Please check to acknowledge

- That my personal and medical information will be treated in the strictest confidence in accordance with the QLD Information Privacy Act 2009

- That all treatment is to be paid for on the day of treatment and that no accounts are issued

- That to keep things fair for all our patients and our staff, we ask you to provide 24 hours notice if you are unable to attend your appointment or require a cancellation

Open 6 Days, Evening & Weekend Appointments Available

07 3357 4177
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