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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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Adult Medical History Form

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Adult Medical History Form

Adult Medical History Form

At Dental as Anything we strive to provide you with the highest possible care.

To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly. Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation.

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

Personal Information
Please note mandatory fields are marked with an asterisk *
Surname*
Title
Given Name*
Preferred Name*
(What do you prefer to be called?)
Date of Birth*

Day
Month
Year
Occupation
Residential Address*
Street Address Suburb State Postcode
Mobile (Preferred)*
Home Phone
Work Phone
Email Address*
Insurance
Do you have Private Health Insurance?*
Private Health Fund Name*
(Position) Line No*
Do you have a DVA (Dept of Vet Affairs) No: ?*
Veterans Affairs (DVA) No:*
DVA Card Type?*
Other way you found us:*

Next of Kin
In case of an emergency, whom would we contact?
Emergency Contact Name:*
Relationship to patient?:*

(eg: mother, father, wife, husband, uncle, aunty, sister, brother, etc.)
Phone Number: (of emergency contact name)*

Medical History
How do you rate your general health?*
- Excellent
- Good
- Fair
- Poor
Do you require antibiotic cover for dental treatment?*
- No
- Yes
Please provide more details:*
Do you smoke?*
- No
- Yes
How many years have you smoked?*
Have you ever smoked?*
- No
- Yes
How many years ago did you smoke?*
When it comes to your oral health... which do you prefer to be?*
- Proactive
- Reactive

Name of your Doctor (General Practitioner):
GP Phone:

Have you had or are you suffering from any of the following?
You must tick Yes or No for each of the following conditions.
Heart Trouble / Surgery*
- No
- Yes
Tuberculosis*
- No
- Yes
Cardiac Pacemaker*
- No
- Yes
Arthritis*
- No
- Yes
Contact with Blood-borne viruses*
- No
- Yes
Thyroid Trouble*
- No
- Yes
Epilepsy*
- No
- Yes
Sleep Apnoea*
- No
- Yes
Stroke*
- No
- Yes
Steroid Therapy*
- No
- Yes
Bronchitis, Emphysema or Lung Condition*
- No
- Yes
Nervous Disorder*
- No
- Yes
Asthmatic*
- No
- Yes
HIV / AIDS*
- No
- Yes
Liver or Kidney Disease*
- No
- Yes
Rheumatic Fever*
- No
- Yes
Osteoporosis*
- No
- Yes
Anaemia, Leukaemia*
- No
- Yes
Eating Disorder*
- No
- Yes
Prosthetic Implant / Joint Replacement*
- No
- Yes
Stomach or Digestive Condition*
- No
- Yes
Excessive or Prolonged Bleeding*
- No
- Yes
Radiation or Chemotherapy*
- No
- Yes
Are you or could you be pregnant?*
- No
- Yes
Blood Pressure*
Diabetes*
Hepatitis*
Please specify any other conditions not mentioned above:
Are you allergic to anything?*
- No
- Yes
What are you allergic to?*
Eg: local anaesthetic, latex, penicillin, peanuts, etc.
Are you currently taking any medications?*
This includes any natural remedies.
- No
- Yes
Please list the medications (including natural remedies) you are taking?*
Additionally, you can upload a list of Medications or Health Summary, dosages and frequency here.
Drop files here or

Max. file size: 200 MB, Max. files: 5.
I have confidential medical information that I do not wish to write down. I would prefer to speak to a dentist about this.
- I have confidential medical information that I do not wish to write down. I would prefer to speak to a dentist about this.
Have you or anyone in your household returned from overseas travel in the last 14 days?*
- No
- Yes
Where did you return from?*
Have you been hospitalised in the last 12 months?*
- No
- Yes
Please describe*
Have you ever had Botox or Facial Fillers?*
- No
- Yes

Dental History
How long has it been since your last dental visit?*
Please tick any dental concerns you have below:
- Bleeding Gums
- Worn, Broken Teeth
- Sounds from Joint
- Grinding / Clenching Teeth
- Bad Appearance of Teeth
- Missing Teeth
- Loose Teeth
- Difficulty Chewing
- Bad Breath
- Rapidly Decaying Teeth
- Unsatisfactory Denture
- Discoloured Teeth
- Dry Mouth
- Pain in Face or Jaw Joints
- Lost Filling / Cavity
- Toothache
- Sensitive Teeth

For Your Comfort
Whilst the improvement in techniques and anaesthetics have helped most people, you may still be apprehensive and wish us to take extra measures for your comfort. Please tick the number that indicates your present level of concern.
1 being Completely at ease and 10 being Petrified*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11+

Consent for Treatment & Communications
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 governmental 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 governmental 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 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.

Signature of Patient (or Guardian if patient is under 18 years old):*
Date of Signature*

Day
Month
Year

Click SUBMIT below, If you have completed all the information required, you will be presented with the "Thank you for Submitting" page.
Please WAIT to see the "Thank You for Submitting Page", otherwise review this form for missing required information, then click Submit again.

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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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