Home » Demo form

New Patient Questionnaire

If you are a new patient please completed the below form and submit it to us.

Download PDF Form


PERSONAL DETAILS

 

 

 

 

How would you like to be contacted to notify you are due for a check up and clean?


Please tick appropriate:
Home phWork phMobileLetter

Referred By:
Yellow PagesAnother patient/friendStreet SignOther

Do you have Health Insurance for dental treatment?
YesNo

Details of person to contact in an emergency:


MEDICAL HISTORY (if Yes, please give details)


Are you receiving any medical treatment at the present time?
YesNo
Have you been a patient in hospital during the past two years?
YesNo
Have you taken any medicine tablets, capsules or drugs during the past two years?
YesNo
Have you experienced any allergies or unusual effects from: tablets, drugs, injections or anaesthetic?
YesNo
Are you, or have you been, under the care of a doctor during the past two years?
YesNo
Do you smoke?
YesNo
Have you ever had or have any of the following? If so, please tick as appropriate
Heart TroubleHigh Blood PressureAsthmaBronchitis/Chest ProblemsHepatitis – Type A, B or CArthritisDepressive IllnessOsteoporosisEpilepsySevere HeadachesKidney TroubleGastric ProblemsAnaemiaCold SoresDrug DependenceRheumatic FeverDiabetes

Have you had any prosthetic surgery? If yes, when? (E.g. Heart Valve, Hip Replacement, Knee Replacement etc)
YesNo
Women Only: Are you pregnant?
YesNo

DENTAL HISTORY



(if you wish your records to be transferred over please let us know)

Do you have Dental pain or a Dental problem at present?
YesNo
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
YesNo

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

I acknowledge that I am responsible for all costs of treatment incurred. Payment for treatment is due on the day of treatment.

Signed: Patient/Parent/Guardian
Date: