MedicalHistoryForm - Fab Dental

Ladies are you pregnant?

Yes No

Do you suspect that you are in a high risk category for HIV or AIDS?

Yes No

Do you require antibiotic cover before dental treatment?

Yes No

Name and location of last Dentist

Approximate date of last dental visit

What treatment did you receive at your last dental visit?

Were you happy with the treatment and care you received at your last dental visit?

Yes No

What have your past dental experiences been?

What is your main dental concern at present?

Are you having any discomfort or sensitivity at present to any of the following:

Hot Cold Sweet Pressure

In which area of the mouth is your concern?

Upper Lower Left Right

What are your expectations from your dental visit today?

When did you last have dental X-rays?

Have you attended the dentist for regular 6 or 12 monthly checkups?

No 6 months 12 months

What's important to you about your teeth?

How do you feel about the appearance of your smile?

If you could change the appearance of your smile, what would you change? (please tick)

Whiter teeth	More Even Smile	Close spaces between teeth
Change shape of teeth	Straighter teeth	Remove silver fillings	Other (specify)

Have you ever suffered any jaw pain?

Yes No

Do you have concerns about losing your teeth?

Yes No

Do you have any missing teeth?

Yes No

Have your wisdom teeth come through?

Yes No

Have you had any of your wisdom teeth removed?

Yes No

Do you wear dentures?

Yes No

Have you ever had any Crowns, Bridges, Veneers or dental implants placed?

Yes No

Do you have dental pain or a dental problem at present?

Yes No

Do you become anxious or uncomfortable when you are having dental treatment?

Yes No

Do you brush and floss daily?

Yes No

Is there anything with appearance of your teeth that you are not happy with?

Yes No

Do you grind your teeth?

Yes No

Do your gums bleed regularly?

Yes No

Is there anything else you would like the dentist to know?

Yes No

Do you give permission for Fab Dental to share your information with your immediate family?

Yes No

Are you a smoker?

Yes No

Gender	Male Female
Title
Full name
Preferred name
Address
Suburb
Postcode
Home phone
Work phone
Mobile
Email
Date of birth
Dental Health Fund

	I understand that failure to complete the medical information may place others and myself at risk.
	I understand that this medical history questionnaire is treated with complete confidentiality.
	I understand that if I fail to give adequate notice to cancel my appointment, that a fee may be charged.
	I agree to be responsible for payment of all services rendered on my behalf and on the behalf of my dependents. I understand that this payment is due at the time of service unless other arrangements have been made.

Medical History Form

Personal details

Emergency contact

Confidential medical history

Declaration

Quick Links

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Rheumatic Fever	Yes No	Epilepsy	Yes No
Heart Condition	Yes No	Bleeding Disorder	Yes No
High Blood Pressure	Yes No	Diabetes	Yes No
Low Blood Pressure	Yes No	Kidney Trouble	Yes No
Arthritis	Yes No	Asthma	Yes No
Hepatitis A	Yes No	Chemotherapy/Radiotherapy	Yes No
Hepatitis B	Yes No	Thyroid Disease	Yes No
Hepatitis C	Yes No	Tuberculosis	Yes No
Bronchitis or Chest Problems	Yes No	Hip or Joint Replacement	Yes No
Severe Headaches	Yes No

Full name
Phone number
Relationship