Melbourne Dental – Medical History Form

Patient Information

Thank you for submitting in your Medical History Form. Should you have any further questions, please do not hesitate to contact us directly.

Surname
Title
First Name
Date of birth
Home Address
Suburb
Postal Code
State
Business Address
Business Postal Code
Do you have private health insurance? (Please state)	Yes No
Health insurance provider
Contact Number
Email
Postal Address (if different from above)
Name of Person responsible for Fees
Address (if different from above)
Emergency Contact
Relationship
Phone
Medical Doctor
Address
Postal Code
Phone
Who recommended this practice to you?
Have you ever had any of the following? Please indicate
High blood pressure	Yes No
Diabetes	Yes No
Heart ailment	Yes No
Thyroid problems	Yes No
Rheumatic fever	Yes No
Excessive bleeding or blood disorder	Yes No
Asthma, chest or breathing problems	Yes No
Epilepsy	Yes No
Tubercolosis	Yes No
Hepatitis	Yes No
Stomach or bowel problems (e.g. Ulcer)	Yes No
AIDS/HIV	Yes No
Kidney disease	Yes No
Bone disorders or diseases	Yes No
Do you smoke?	Yes No
How many per day?
Would you like to stop?	Yes No
List any other previous illnesses
Would you like to discuss these questions in private with the dentist?	Yes No
Do you have an artificial hip, heart valve, or other prosthetic implant?	Yes No
Have you ever had problems with dental treatment?	Yes No
Are you presently under medical care?	Yes No
Are you taking any drugs, medicines or tablets? (Please list)	Yes No
List drugs, medicines or tablets
Female patients, are you pregnant?	Yes No
Do you have allergies?	Yes No
List any medicines or products you are allergic to (e.g. Penicillin, Latex)

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