Medical History Form LoginRetrieve my historyThank you for choosing Simply Teeth. To ensure we are looking after all your dental needs, we appreciate you taking the time to complete this confidential form.PATIENT DETAILSTitle: *Please selectMs.Mr.Mrs.Miss.Dr.First name *Surname *Preferred nameDOB *Address *Suburb *State *Postcode *Mobile phone *Phone(home)Phone (work)E-mail *OccupationReferred to our practice by: Google Internet Health fund Friend/Family Other Is another member of your family a patient at our practice?Please select12345678910Name of family memberName of person responsible for fees, if not self:Emergency contact person:Emergency contact relationship:Emergency contact phone:Health FundPlease selectNoneCBHSHBFMedibankNIBBupaWest FundTUHUnion HealthAHMCUAMRNAANZFrankPolice HealthOtherMembership No.Membership Patient ID.CONDITIONS Smoker Bleeding/Bruising easily Problems with wound healing Diabetes High/Low blood pressure Heart disease/stroke Hep A, B, C, D or E Anaemia/Iron deficiency Asthma Anxiety Low bone density Acid reflux Epilepsy Chemotherapy Radiotherapy Family history of diabetes Heart disease High blood pressure Migraines Cancer Hip/knee replacement Past-current long/serious illnesses Previous surgical procedures Previous hospitalisatioon Adverse drug reactions Hypothyroidism Cold sores Thyroid disease Physical or mental impaiment Autoimmune conditions Please list details and any conditions not mentioned aboveList your current medications/drugs belowAllergies Penicillin Codeine Adhesives Latex Other Are you pregnant or planning pregnancy? Yes No HIV / AIDS * Yes No Any other infectious disease(s)DENTAL HISTORYWhen was your last dental visitPurpose of visit *Please selectCheck-upProfessional scale and cleanToothacheFillingTeeth whiteningDentureInvisalignWisdom teethMouthguardEmergency dentalDental crowns and bridgeVeneersRoot canal treatmentImplantConsultationOtherPast Dental TreatmentDoes your jaw "click" or hurt? Yes No Do you feel you grind or clench your teeth? Yes No Do you wear a dental night guard? Yes No Have you had orthodontic treatment? Yes No Do your gums ever bleed? Yes No Do you get bad breath? Yes No Have you had or do you have gum disease? Yes No Do you experience hot/cold sensitivity? Yes No Do your teeth hurt when you bite? Yes No Does floss ever tear between your teeth? Yes No Does food get jammed between your teeth? Yes No Do you ever get headaches? Yes No Do you/have you been told you snore? Yes No Do you feel unrefreshed upon waking from sleep / Are you "dragging" yourself through the day? Yes No Have you had a sleep study or have sleep apnoea? Yes No CONSENT TO TREATMENT I hearby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand I can ask for a complete recital of possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service. In the event that you need to reschedule or cancel an appointment, we require a minimum notice of 2 business days.To the best of my knowledge, the questions on the form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental practice of any changes in medical status.Patient signature (Guardian if under 18) *Confirmed Clear Submit