Medical History Form

The following details regarding your medical history are designed to identify factors that may influence the best deliver of your dental care. All information provided by you will be treated with complete confidentiality in accordance with the Privacy Act. Read our Privacy Policy here.

Personal details

Full name
Preferred name
Home phone
Work phone
Date of birth
Dental Health Fund

Emergency contact

Full name
Phone number

Confidential medical history

Are you under treatment from a medical practitioner ?
Are you taking any medication at present?
If yes, please list medication  details
Do you have any allergies or unusual effects from tablets, injections or anaesthetic?

Please indicate if you have or have had any of the following conditions:

Rheumatic Fever Epilepsy
Heart Condition Bleeding Disorder
High Blood Pressure Diabetes
Low Blood Pressure Kidney Trouble
Arthritis Asthma
Hepatitis A Chemotherapy/Radiotherapy
Hepatitis B Thyroid Disease
Hepatitis C Tuberculosis
Bronchitis or Chest Problems Hip or Joint Replacement
Severe Headaches     
Ladies are you pregnant?
Do you suspect that you are in a high risk category for HIV or AIDS?
Do you require antibiotic cover before dental treatment?
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?
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:
In which area of the mouth is your concern?
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?
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)
More Even Smile  
Have you ever suffered any jaw pain?
Do you have concerns about losing your teeth?
Do you have any missing teeth?
Have your wisdom teeth come through?
Have you had any of your wisdom teeth removed?
Do you wear dentures?
Have you ever had any Crowns, Bridges, Veneers or dental implants placed?
Do you have dental pain or a dental problem at present?
Do you become anxious or uncomfortable when you are having dental treatment?
Do you brush and floss daily?
Is there anything with appearance of your teeth that you are not happy with?
Do you grind your teeth?
Do your gums bleed regularly?
Is there anything else you would like the dentist to know?
Do you give permission for Fab Dental to share your information with your immediate family?
Are you a smoker?


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.