Medical History

If you are a new patient requesting an appointment, we will need you to complete a medical history questionnaire providing us with information that will help us to treat your individual needs. This can be done at our practice before your appointment, online or you can print out our medical history questionnaire to complete at your leisure before your appointment.

Please fill in the online form below or if you prefer, please download Word version of the form and email the form to info@thedentistshornsby.com.au or info@rawsondental.com.au

Welcome to Sydney Dental Sedation!

Thank you for giving us the opportunity to care for your oral health and smile. In order to provide high standard of care and treatment, please review and complete the following questionaire. It will be handled confidentially.

Medical History

Email*
Title
First Name*
Surname*
Date of Birth
Address
Postcode
Home Number
Work Number
Mobile Number
Occupation
Emergency Contact
Private Health Fund
Member Number
If less than 18years old, parent/responsible party:

How did you hear about the Practice?

 Internet/Website
 Yellow Pages
 Walked past
 Letter Drop
 Dentist/ Doctor
 Recommended
 Other
If Doctor/Dentist please state who
If Recommended, who by
If Other, please specify
Is another member of the family a patient at our office: Yes No

What is the main purpose of your visit today?

Name of your GP
Phone
Address
Have you had any of the following Medical Issues? please tick
Heart Problems / Disease
 Yes No
Blood Pressure
 Yes No
Artificial Joints
 Yes No
Rheumatic Fever
 Yes No
Heart Valve replaced/leaky
 Yes No
Circulatory Problems
 Yes No
Excessive Bruising /Bleeding
 Yes No
Liver or Kidney Disease
 Yes No
Radiation Treatment
 Yes No
Stomach Ulcers
 Yes No
Cancer
 Yes No
Sleep Apnoea
 Yes No
Psychological Disorder
 Yes No
Allergies to Anaesthetic / Latex
 Yes No
Allergies to Penicillin
 Yes No
Allergies to Medications
 Yes No
Sinus Problems
 Yes No
Anaemia or other blood problems
 Yes No
Diabetes
 Yes No
Asthma
 Yes No
Epilepsy
 Yes No
Hepatitis A, B, C or D
 Yes No
Tuberculosis or CJD or HIV or AIDS
 Yes No
Infectious Diseases
 Yes No
Dizziness/Fainting
 Yes No
On Warfarin
 Yes No
Are you Pregnant?
 Yes No
if so, what is your due date?
Are you currently taking any medications?
 Yes No
Are you taking or have you taken any Bisphosphonate drugs? Yes No
If YES please provide details
Have you had any of the following dental issues?
Does your jaw click or hurt?
 Yes No
Do you feel you grind your teeth?
 Yes No
Orthodontic Treatment?
 Yes No
Do you wear a guard at night?
 Yes No
Sensitivity to hot or cold?
 Yes No
Have you had gum Disease?
 Yes No
Do you smoke?
 Yes No
Bad Breath?
 Yes No
Bleeding Gums
 Yes No
Pain on bitting hard?
 Yes No
Food jamming between teeth?
 Yes No
Problems flossing?
 Yes No
Other Notes or Concerns you would like us to know about?
How long since your last dental visit?
How often do you have dental examinations?
Previous dental xrays were taken: Less than a year ago? Longer than a year ago?

Consent for Treatment

I hereby authorise the dentist or designated team to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I understand I can ask for a complete recital of any complications associated with treatment I may need. I agree to be responsible for payment of all sevices rendered on my behalf and on behalf of my dependents. I understand that payment is due at the end of service unless other arrangements have been made. I authorise that this information may be reviewed by team members of the dental practice.
Today's date