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9 Sir John Overall Dr, Helensvale, QLD 4212

8.30 AM – 5.00 PM 9.00 AM – 7.00 PM 9.00 AM – 5.00 PM 7.00 AM – 3.00 PM 8.00 AM – 3.00 PMCLOSEDCLOSED

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Child Medical History Form

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Child Medical History Form

Child Medical History Form

For children up to 12 years

Welcome to Dental as Anything where we provide individualized care for infants, toddlers, children and teens. Our focus is on prevention and early management of dental disease. We are honoured that you have entrusted your child’s care to us. We take great pride in providing a comfortable experience for children and their families. Should you have any special requests, please inform us and we will do our best to accommodate you.

How did you find us?*
- Patient or Friend Referral
- Facebook
- Professional Referral
- Family Referral
- Practice Website
- Staff Referral
- Signage
- Google
- Other
Who may we thank for referring you?*
What other way did you find us?*
If yes, what did you search for?*

Tell us about your child
Surname*
Given Name*
Preferred Name*
Date of Birth*

Day
Month
Year
Age*
School
Grade
Other siblings we treat
Residential Address*
Street Address Suburb State Postcode
Mobile (Preferred)*
(Parent or Guardian)
Home Phone
(Parent or Guardian Home)
Favourite Movie
Favourite song/singer
Favourite activity
Do you have private health insurance?
- No
- Yes
Name of Private Health Fund*
Position Number on card*
Medicare Number*
Position Number on Card*

Parent / Guardian
Name 1*
Phone 1*
Email*
Name 2
Phone 2

Who is accompanying your child today?
Name*
Relationship*
Do you have legal custody of your child?*
- No
- Yes
Medical History
Please indicate your child's current general health:*
- Excellent
- Good
- Fair
- Poor

Name of your Doctor (General Practitioner)
GP Phone

Has your child ever had the following? (please tick yes or no)
Kidney or liver conditions*
- No
- Yes
Blood disorders*
- No
- Yes
Sickle cell disease*
- No
- Yes
Operations*
- No
- Yes
Disabilities / special needs*
- No
- Yes
Cancer*
- No
- Yes
Heart disease or murmur*
- No
- Yes
HIV+ / AIDS*
- No
- Yes
Rheumatic / scarlet fever*
- No
- Yes
Asthma*
- No
- Yes
Congenital birth defects*
- No
- Yes
Autism*
- No
- Yes
Epilepsy*
- No
- Yes
Tuberculosis*
- No
- Yes
Abnormal bleeding*
- No
- Yes
Hearing impairment*
- No
- Yes
ADD / ADHD*
- No
- Yes
Other*
- No
- Yes
Other condition(s) (Please specify):*
Diabetes*
Hepatitis*
Have you or anyone in your household returned from overseas travel in the last 14 days?*
- No
- Yes
Where have you returned from?*
Have you been hospitalised in the last 12 months?*
- No
- Yes
Please describe*
Is your child currently taking any medications? (This includes natural remedies)*
- No
- Yes
Please list all medications*
Does your child have any allergies? Eg: local anaesthetic, latex, penicillin, peanut, etc.*
- No
- Yes
Please list allergies*
Dental History
Is this your child's first visit to a Dentist?*
- No
- Yes
How long since the last visit?*
Previous dentist’s name
Were any X-rays taken at previous dental visits?*
- No
- Yes
Any injuries to the teeth, face or mouth?*
- No
- Yes
Please describe,*
Family history of dental problems?*
- No
- Yes
Please describe,*
Why did you bring your child to the dentist today?*
Do you have any dental concerns or questions?*
- No
- Yes
Please list your dental concerns or questions?*
Have previous dental visits been*
- Positive
- Negative
Please describe why it was negative?*

Do any of the following apply to your child
- Frequent snacking
- Sleeping with a bottle
- Pacifier use
- Breast-feeding
- Tooth grinding
- Thumb sucking
Cups per day of:
Milk:
Juice:
Fizzy drinks:
Cups per night of:
Milk:
Juice:
Fizzy drinks:

Is there anything we can do to help make your child more comfortable?
Dental care at home
Brush his or her own teeth?*
- No
- Yes
How often a day?*
Difficulty brushing his or her teeth?*
- No
- Yes
Does your child use xylitol products?*
- No
- Yes
Does your child floss daily?*
- No
- Yes
Do you floss your child's teeth?*
- No
- Yes
Does your child use flouride toothpaste?*
- No
- Yes
Is your child taking flouride supplements?*
- No
- Yes
Is your child able to spit?*
- No
- Yes

Consent for Treatment
I am happy to receive SMS and Email communication from Dental as Anything for critical or pertinent appointment reminders and any other information that pertains to dental awareness, health fund or government changes.*
- I am happy to receive SMS and Email communication from Dental as Anything for critical or pertinent appointment reminders and any other information that pertains to dental awareness, health fund or government changes.
I hereby consent to dental treatment deemed necessary by the dentists and agreed by my verbal consent beforehand to be carried out. I understand that it will be discussed with me before any staff takes x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.*
- I hereby consent to dental treatment deemed necessary by the dentists and agreed by my verbal consent beforehand to be carried out. I understand that it will be discussed with me before any staff takes x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
I agree to be responsible for the payment of all services rendered on my behalf and on behalf of my dependants. I understand that payments are due at the time of service.*
- I agree to be responsible for the payment of all services rendered on my behalf and on behalf of my dependants. I understand that payments are due at the time of service.
I understand that payments are due at the time of service.*
- I agree to be responsible for the payment of all services rendered on my behalf and on behalf of my dependants. I understand that payments are due at the time of service.

Signature*
Full name of person signing, on behalf of child*
Date*

Day
Month
Year

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8.30 AM – 5.00 PM 9.00 AM – 7.00 PM 9.00 AM – 5.00 PM 7.00 AM – 3.00 PM 8.00 AM – 3.00 PM CLOSED CLOSED

9 Sir John Overall Dr, Helensvale, QLD 4212

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