Medical History

PLEASE NOTE!

This form uses headings above the answers. Where applicable, the question is under the answers.
We deidentify the health information you provide here using details to identify you, which only we can decode.

PATIENT STATUS:

- First time patient
- Already a valued patient

APPOINTMENT BOOKED:

- Online
- Over the phone
- At the practice

How did you set your dental appointment?

MEDICAL HISTORY DONE:

- Not previously done
- Yes, more than 12 months ago, and there have been no changes in my health
- Yes, more than 12 months ago, and there have been some changes in my health
- Yes, less than 12 months ago, and there have been some changes in my health

Have you previously completed this medical history questionnaire?

UNIQUE PATIENT IDENTIFER#:

- Yes
- No

Check the SMS or email with the link to this form for your Unique Patient Identifier.

UPI#:

By entering your UPI, we can seamlessly link the answers you provide in this questionnaire with your patient file in our practice management software, ensuring a smooth and efficient process.

PATIENT FIRST NAME:

We use the patient's first name and linked mobile phone to help identify you. Please do not provide the patient's full name.

AGE:

Age of the patient in years.

MY CONTACT DETAILS:

- Have not changed
- May have changed

Has your phone number or email changed?

PATIENT PHONE:

The phone number you provided when setting the dental appointment for yourself or your dependent. It helps up identify the patient.

PATIENT EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

BODY MASS:

- Metric (cm and kg)
- Imperial (ins and lbs)

Select which units of measure you will use for your height and weight.

WEIGHT (pouds):

What is the approximate weight of the patient in pounds?

HEIGHT (inches):

What is the approximate height of the patient in inches?

WEIGHT (kilograms):

What is the approximate weight of the patient in kilograms?

HEIGHT (centimeters):

What is the approximate height of the patient in centimetres?

I IDENTFY AS:

What gender do you identfy as?

GENDER:

- Female (genetic)
- Male (genetic)
- Other

Select one.

PATIENT IDENTFY AS:

What gender does the patient identfy as?

GENDER THERAPY:

- Yes
- No

Have there been hormones or other medications taken as gender therapy?

Gender Hormones

Informing your dentist about gender medications is essential for safe and effective treatment, avoiding complications and ensuring proper care.

GENDER MEDICATION:

What is the name of your gender medication?

PREGNANCY:

- I may be pregnant
- I am pregnant
- I am not pregnant
- I am in an IVF programme

WEEKS PREGNANT:

How many weeks are you pregnant?

COMPLETED BY:

Who completed this form?

Questionnaire Completed By

We require some contact details of the person who completed this form.

STAFF NAME:

PARTNER NAME:

First

Last

PARTNER PHONE:

We must collect this phone number in case of emergencies involving the patient.

PARTNER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

PARENT NAME:

First

Last

PARENT PHONE:

We must collect this phone number in case of emergencies involving the patient.

PARENT EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

GUARDIAN NAME:

First

Last

GUARDIAN PHONE:

We must collect this phone number in case of emergencies involving the patient.

GUARDIAN EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

FOSTER CARER NAME:

First

Last

FOSTER CARER PHONE:

We must collect this phone number in case of emergencies involving the patient.

FOSTER CARER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

CARER NAME:

First

Last

CARER PHONE:

We are required to collect this phone number you in case of emergencies involving the patient.

CARER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

Health Questionnaire

HEART CONDITION:

- No
- Yes

Have you ever had a heart condition?

Heart Conditions

Your dentist must be aware of any heart conditions you have because heart health significantly influences dental treatment outcomes and can impact the safety and effectiveness of dental procedures.

HEART CONDITION TYPE:

Have you ever had a heart condition such as a Heart Valve Replacement, Heart Murmur, Arrhythmia, Heart Attack, Open Heart Surgery, Pacemaker placed, or Bypass Surgery…? Select all that apply.

HEART VALVE REPLACED:

What year was your heart valve surgery done?

PACEMAKER PLACED:

What year was your pacemaker placed?

OPEN HEART SURGERY:

What year was your open heart surgery done?

BY-PASS SURGERY:

What year was your by-pass surgery done?

OTHER HEART CONDITION:

Please provide more details about you Other Heart Condition.

HEART MEDICATION:

- Yes
- No

Are you taking any medication for your heart condition?

HEART CONDITION MEDICATIONS:

What is the name, dose, and frequency of your heart medication?

PROPHYLACTIC ANTIBIOTICS:

- No
- Yes
- I am not sure

Have you been advised by your heart doctor to take antibiotics before you have dental treatment?

Critical Health Information Required!

Please get in touch with your heart doctor or GP and ask if you must take antibiotics before a dental procedure that may trigger bleeding from the gums. Once you have the answer to this critical question, update the dentist or receptionist.

BLOOD BRESSURE:

- No
- Yes

Have you ever had a Blood Pressure condition such as low or high blood pressure?

Blood Pressure Conditions

Your dentist needs to know what blood pressure condition you have because blood pressure plays a significant role in oral health and can impact dental treatment outcomes. Here are key reasons why sharing information about your specific blood pressure condition with your dentist is crucial.

BLOOD PRESSURE CONDITION:

- High blood pressure
- Low blood pressure

BLOOD PRESSURE MEDICATION:

- Yes
- No

Are you taking any medication to manage your blood pressure?

BLOOD PRESSSURE MEDICATION DETAILS:

LIVER CONDITIONS:

- Yes
- No

Have you had liver conditions such as Hepatitis, Fatty Liver disease, Cirrhosis...?

Liver Disease

Your dentist must know what liver disease you have because liver health plays a significant role in oral health and can affect dental treatment outcomes.

LIVER DISEASE:

- Hepatitis A
- Fatty liver disease
- Liver Cirrhosis
- Other Liver Condition

What Liver conditions have you had? Select all that apply.

OTHER LIVER CONDITION:

Please provide more about your other liver condition..

KIDNEY CONDITION:

- No
- Yes

Have you had a Kidney Condition such as Multicystic Dysplastic Kidney, Nephrotic Syndrome in Adults, Pain Medicine & Kidney Damage, Polycystic Kidney Disease (PKD), Renal Artery Stenosis, Renal Tubular Acidosis, Simple Kidney Cysts., Solitary or Single-functioning Kidney...?

Kidney Conditions

Your dentist must be aware of any kidney disease or conditions you have because these can significantly affect your oral health and influence dental treatment.

TYPE OF KIDNEY CONDITION:

What is the kidney condition? Select all that apply.

ANTI-REJECTION MEDICATION:

- Yes
- No

Are you taking anti-rejection medication for the kidney transplant?

ANTI-REJECTION MEDICATION:

Provide Name, Dose and Frequency the medication.

OTHER KIDNEY CONDITION:

Describe you Other Kidney Condition.

BONE CONDITION:

- Yes
- No

Do you have a Bone Condition or Disease such as osteoporosis, Osteopenia, Paget's disease, Osteogenesis imperfecta, Osteoarthritis, Osteomyelitis, Bone cancer and tumours, or Osteomalacia?

Bone Disease

Your dentist must be informed about any bone diseases you have because these conditions can directly impact your oral health and influence dental treatment decisions.

BONE CONDITION TYPE:

What is your Bone Disease? Select all that apply.

OSTEOPOROSIS MEDICATION:

- Yes, taking medications
- I have stopped taking medication
- Never taken any medications

Are you taking any medication, supplements or alternative medicines for the osteoporosisJ

JOINT REPLACEMENT DATE:

When was the last joint replacement done? Year and month if known.

OTHER BONE CONDITION:

What is the other bone disease?

PROPHYLACTIC ANTIBIOTICS:

- Not needed
- Needed
- Not sure

Have you been advised to take antibiotics before dental treatment, such as extractions or dental cleaning?

GASTROINTESTINAL, STOMACH & DIGESTIVE:

- No
- Yes

Have you had any gastrointestinal, stomach or digestive conditions such as Reflux, Oesophageal Condition, Stomach Ulcer, Chron's Disease, Celiac disease, GORD (Gastro-Oesophageal Reflux Disease), Peptic Ulcer, Ulcerative Colitis, Diverticulitis, Malabsorption, Gastric Banding, Short Bowel Syndrome, Polyps or, Cancer?

Gastrointestinal, Stomach or Digestive Conditions

Some gastrointestinal diseases present with oral manifestations or symptoms, such as ulcers, lesions, or inflammation in the mouth.

GASTROINTESTINAL CONDITION:

What Gastrointestinal, Stomach or Digestive Conditions, do you have? Select all that apply.

OTHER GASTRIC SURGERY:

Provide details about the Other Gastric Surgery you have undergone.

OTHER GASTROINTESTINAL CONDITION:

Provide details about the other Gastrointestinal Conditions?

GASTROINTESTINAL MEDICATION:

- No
- Yes

Are you taking any medications for the gastrointestinal conditions?

MEDICATION TYPE:

Provide the Name, Dose and Frequency of your medication for the gastrointestinal condition.

LUNG DISEASE:

- No
- Yes

Do you have a lung condition such as Asbestosis, Asthma, Bronchiectasis, Bronchitis, Bronchiolitis, Chest Infection, Chronic Obstructive Pulmonary Disease (COPD), Cystic Fibrosis, Pulmonary Oedema?

Lung Disease

Patients with lung conditions such as asthma, chronic obstructive pulmonary disease (COPD), or other respiratory issues may have difficulty breathing during specific dental procedures. Additionally, some medications used in dentistry can affect the respiratory system.

Understanding a patient's lung condition allows the dentist to tailor treatment plans and take necessary precautions to ensure their safety and well-being during their dental visit. It also helps determine the most suitable anesthesia and sedation options and identify potential complications that may arise due to compromised lung function.

Ultimately, being aware of a patient's lung condition enables the dentist to provide appropriate care that minimises risks and maximises comfort for the individual undergoing dental treatment.

.

LUNG CONDITION:

What lung conditions do you have? Select all that apply.

LUNG CONDITION TREATMENT:

- No
- Yes

Do you require any form of treatment for your lung condition?

LUNG CONDITION TREATMENT:

- I take some medication
- I require breathing support such as Oxygen
- I require no treatment

What treatment do you require for your lung condition?

LUNG CONDITION MEDICATION:

Provide the Name, Dose and Frequency of your medication for the lung condition.

BREATHING SUPPORT:

Please describe the breathing support you need for your lung condition.

MENTAL HEALTH:

- No
- Yes

Do you have a mental health condition such as Anxiety Disorders, Depression, Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Schizophrenia, Eating Disorders, Disruptive behaviour and dissocial disorders, or Neurodevelopmental disorders..?

Mental Health

Your dentist must know about any mental health conditions you have because mental health can significantly impact your oral health and dental treatment.

MENTAL HEALTH CONDITION:

What mental health conditions do you have? Select all that apply

OTHER MENTAL HEALTH CONDITION:

What other mental health conditions do you have?

MENTAL HEALTH MEDICATION:

- No
- Yes

Are you taking any medications for your mental health condition?

ANXIETY MEDICATION:

Please write the medication name, does and frequency of medication are you taking for anxiety.

DEPRESSION MEDICATION:

Please write the medication name, does and frequency of medication are you taking for depression?

SCHIZOPHRENIA MEDICATION:

Please write the medication name, does and frequency of medication are you taking for schizophrenia.

ADHD MEDICATION:

Please write the medication name, does and frequency of medication are you taking for ADHD.

AUTISM MEDICATION:

Please write the medication name, does and frequency of medication are you taking for autism.

OTHER MENTAL HEALTH MEDICATION:

Please write the medication name, does and frequency of medication are you taking for your other meant health condition.

Headaches

Headaches can often be linked to various dental issues, such as jaw joint disorders, teeth grinding and bite alignment. We can identify potential underlying causes from the oral cavity by asking patients about their headache history and symptoms.

HEADACHES:

- Yes
- No

Do you experience headaches?

HEADACHE EXPERIENCE:

- Started recently
- Commenced some time ago
- My headaches started after an event that happened to me
- I have had them for as long as I can remember

Do you experience headaches?

HEADACHE TRIGGERING EVENT:

Describe the event that triggered the headaches.

HEADACHES COMMENCED:

How long ago did your first headache start?

HEADACHE OCCURENCE:

- No pattern
- Usually at a specific time of the day

Do your headaches occur at specific times of the day?

HEADACHE FREQUENCY:

How often do you experience these headaches? Select the most appropriate option.

DAILY HEADACHE PATTERN:

- Morning
- Middle of the day
- Evening
- Other

Do your headaches occur at specific times of the day?

OTHER DAILY HEADACHE PATTERN:

What time of the day or night do your headaches usually occur?

HEADACHE PAIN DESCRIPTION:

Select all that apply to describe the pain experience.

HEADACHE PAIN DECERIPTION OTHER:

Describe the headache pain type.

HEADACHE TRIGGERS:

- No
- Yes

Have you noticed any triggers that may worsen your headaches?

HEADACHE TRIGGER DETAIL:

What are your headache triggers?

NEUROLOGICAL:

- Yes
- No

Have you had any Neurological Conditions such as Stroke, Neonatal Encephalopathy, Headached, Migraine, ADHD, Dementias, Diabetic Neuropathy, Meningitis, Epilepsy, Neurologic Complications from Preterm Birth, Autism Spectrum Disorder, Nervous System Cancers...?

Dental Care & Neurological Conditions.

Neurological conditions can impact oral health and treatment. Conditions such as epilepsy, Parkinson's disease, multiple sclerosis, or stroke can affect muscle control, sensation, coordination, and overall oral function.

NEUROLOGICAL DISORDER:

Select all that apply.

NEUROLOGICAL MEDICATION:

- Yes
- No

NEUROLOGICAL MEDICATION:

Provide the Name, Dose and Frequency of your medication for the neurological condition.

OTHER NEUROLOGICAL:

Details of the other neurological condition ytou have experienced.

BLOOD CONDITIONS:

No
Yes

Have you had any blood diseases or disorders such as Leukemia, Lymphoma, Myeloma, Hemochromatosis, Hemophilia, Henoch-Schönlein Purpura, Immune Thrombocytopenia, Iron-Deficiency Anemia, Pernicious Anemia, Venous Thromboembolism (Blood Clots), Hemophilia, Hereditary Hemorrhagic Telangiectasia (HHT), Sickle Cell Disease, Thalassemia, Vitamin K Deficiency Bleeding, Von Willebrand Disease…?

Blood Conditions

Dental treatments such as extractions, surgeries, or periodontal therapies may require modifications for patients with blood disorders to ensure optimal outcomes and minimise complications.

Dentists must consider these conditions when developing treatment plans to provide safe and effective care.

BLOOD CONDITION DETAILS:

What blood disorder or conditions do you have? Select all that apply.

OTHER BLOOD CONDITION:

Please write the name of your other blood condition.

BLOOD CONDITION MEDICATION:

Please write the name of the medication or supplement and the dose and frequency of your drug or supplements.

STROKE:

- Yes
- No

Have you ever had a stroke or sometimes called a brain attack?

Stroke

A history of stroke may require special considerations during dental procedures, as certain medications, mobility issues, and cognitive impairments associated with stroke can impact dental care planning and the choice of treatments.

STROKE DATE:

What is the year you had your last stroke?

STROKE PREVENTION:

- Yes
- No

Are you taking any medication or supplements for stroke management?

STROKE MEDICATION:

Please write the medication or supplements name, does and frequency for Stroke prevention.

BLOOD-BORNE VIRUS:

- No
- Yes

Have you been diagnosed with any of the blood-borne viruses; HIV, Hepatitis B, Hepatitis C or other virus.

Blood-Borne Viruses

HIV / AIDS
Hepatitis B of C
Other Virus

Declaring your blood-borne viruses to your dentist is crucial to ensure proper precautions to prevent the spread of infections and provide tailored treatment, safeguarding your health and the dental team's well-being.

BLOOD-BORNE VIRUS NAME:

- HIV / AIDS
- Hepatitis B
- Hepatitis C
- Other

Select the type of blood-borne virus infection you had.

BLOOD-BORNE VIRUS (OTHER):

What is the other blood-borne virus you had?

HEPATITIS C CARRIER:

- Yes
- No

Are you a Carrier of Hepatitis C, or have you been told that you can infect others?

HEPATITIS B CARRIER:

- Yes
- No

Are you a Carrier of Hepatitis B, or have you been told that you can infect others?

HIV / AIDS CARRIER:

- Yes
- No

Are you a Carrier of HIV / AIDS, or have you been told that you can infect others?

OTHER BLOOD-BORNE VIRUS:

What is the Other Blood Borne Virus you have had?

HIV / AIDS TESTING:

HIV TEST TYPE:

- Antibody tests
- Antigen/antibody test
- Nucleic acid tests (NAT)
- I do not remember

Select the HIV test you have recently had.

HIV / AIDS TEST STATUS:

- Positive
- Negative
- HIV-indetermined
- I do not remember

IMMUNE CONDITION:

- Yes
- No

Do you have an immune condition such as Addison disease, Celiac disease, Dermatomyositis, Graves disease, Hashimoto thyroiditis, Crohn's disease, Ulcerative colitis, Multiple sclerosis, Myasthenia gravis, Pernicious anemia, Reactive arthritis, Rheumatoid arthritis, Sjögren syndrome, Lupus…

Immune Condition

Declaring your immune condition is critical to safeguarding your health.

IMMUNE CONDITION NAME:

Which of the above immune conditions do you have?

IMMUNE CONDITION:

What immune condition do you have?

IMMUNE MEDICATION:

What medication or supplements are you taking for this immune condition?

CANCER:

- No
- Yes

Have you had cancer?

Cancer

Specific cancer treatments, such as chemotherapy and radiation, can adversely affect oral health, including increased risk of infections, inflammation, and dental issues like dry mouth and mucositis.

CANCER RADIATION THERAPY:

- No
- Yes

Have you had radiation therapy for cancer?

RADIATION THERAPY LOCATION:

- Head, neck or jaws
- Other location

Did the radiation therapy involve the head or neck, or jaws?

RADIATION THERAPY FINISHED:

How many months ago did the radiation therapy finish?

CANCER CHEMOTHERAPY:

- No
- Yes

Have you had chemotherapy for cancer?

CHEMOTHERAPY STATUS:

- Undergoing now
- Stopped some time ago

Make a selection to tell us more about your cancer chemotherapy.

CHEMOTHERAPY STOPPED:

How many months has it been since you stopped chemotherapy for cancer?

CHEMOTHERAPY MEDICATION:

What chemotherapy medications are you taking?

CANCER SURGERY:

- No
- Yes

Have you had cancer surgery?

CANCER SURGERY LOCATION:

What part of the body did you have cancer surgery on?

THYROID CONDITION:

- Yes
- No

Do you have a thyroid condition, such as Hyperthyroidism, Hypothyroidism, Hashimoto's Thyroiditis, Thyroid Tumors, Postpartum Thyroiditis, Graves' Disease, Goiter, Thyroid Removal...?

Thyroid Conditions

Thyroid disorders can impact oral health by causing symptoms like dry mouth, gum disease, and altered taste sensation.

THYROID CONDITION TYPE:

Select the thyroid condition that applies to you.

OTHER THYROID CONDITION:

Provide some detail about your other thyroid condition.

THYROID TREATMENT:

- Yes
- No

Are you receiving any treatment for your thyroid condition?

THYROID MEDICATION:

- Yes
- No

Have you taken any prescription medications or supplements for your thyroid condition?

THYROID MEDICATION:

What is the thyroid medication or supplements do you take?

TUBERCULOSIS:

- No
- Yes, I have been diagnosed with TB
- Yes, I have been in close contact with someone that has infectious tuberculosis

Have you had Tuberculosis or recently been in contact with someone who has Tuberculosis?

TUBERCULOSIS TREATMENT:

- No
- Yes

Are you taking any medication or supplements for the tuberculosis?

TUBERCULOSIS SYMPTOMS:

Have you experienced any of the above tuberculosis symptoms?

TUBERCULOSIS MEDICATION:

What is the medication or supplements are you taking for Tuberculosis treatment?

DIABETES:

- No
- Yes

Do you have diabetes?

DIABETIC:

- Type 1
- Type 2
- Pre-Diabetic

What type of Diabetes do you have?

DIABETES MANAGEMENT:

- Medication
- Diet

How are you managing your Diatetes? Select all that apply.

DIABETES MEDICATION:

What medication or supplements are you taking for your diabetes?

RHEUMATIC FEVER:

- No
- Yes

Have you ever had Rheumatic Fever?

EYE CONDITION:

- No
- Yes

Do you have an eye condition, or need to wear glasses for reading?

Eye Conditions

Informing your dentist about your eye conditions is essential as certain conditions may have implications for your dental care, such as assessing cosmetic dental work for approval.

EYE TREATMENT:

- I need to wear glasses reading
- I need to wear glasses for driving
- I am taking medication for the eye condition
- I am receiving no treatment for my eye condition
- Other eye treatment

Select all that apply.

OTHER EYE TREATMENT:

Describe the other eye treatment.

EYE MEDICATION:

What medication or supplements are you taking for your Eye condition?

SKIN CONDITION:

- No
- Yes

Do you have any skin condition such as chthyosis, Pachyonychia Congenita. Pemphigus. Psoriasis. Raynaud's Phenomenon. Rosacea, Vitiligo, Scleroderma?

Skin Conditions

It is essential to inform your dentist about any skin conditions you are experiencing, as specific oral health issues may be linked to or impacted by skin conditions.

SKIN CONDITION NAME:

Write the name or describe your skin condition?

SKIN TREATMENT:

- No
- Yes

Are you taking any medication or supplements for your skin condition?

SKIN MEDICATION:

Name of skin condition medication or supplements, its does and frequency.

Sleep

Snoring and sleepiness during the day can be a symptom of sleep apnea. It can also impact oral health by increasing the risk of issues like dry mouth, tooth decay, gum disease, and tooth grinding.

SNORING:

- Yes, my sleep partner has told me I snore
- No, my sleep partner has not mentioned I snore
- Yes, I have observed my child snoring
- No, I have not obeserved my child snoring
- Not sure, as I do not have a sleep partner

Do you snore, or have you been told that you snore?

SLEEP STUDY:

- Yes, and I have a diagnosis of sleep apnea
- I have been advised to undergo a sleep study
- I am having a sleep study done soon
- I am considering having a sleep study
- No sleep study done

Have you ever undergone a sleep study?

SLEEP APNEA SYMPTOMS:

Do you experience any of the above symptoms? Select all that apply.

Sleepiness Check Needed!

Please complete the Epworth Sleepiness Scale below.

This scale helps assess your daytime sleepiness and can indicate a potential sleep disorder affecting your health and daily functioning. Completing the scale can provide valuable insights for diagnosis and treatment.

DOZING SITTING & READING:

0 - Zero chance of dozing
1 -Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance dozing when sitting and reading. Select one.

DOZING WATCHING TELEVISION:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 -Hhigh chance of dozing

Rate your dozing chance when sitting and reading. Select one.

DOZING DURING INACTIVE SITTING:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing during inactive sitting and reading. Select one.

DOZING AS A CAR PASSENGER:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing during inactive sitting and reading. Select one.

DOZING WHILE SITTING AFTER LUNCH:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing while sitting after a lunch. Select one.

DOZING WHILE SITTING & TALKING:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing while sitting and talking. Select one.

DOZING DURING AN AFTERNOON REST:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing during an afternoon rest. Select one.

DOZING DURING A TRAFFIC JAM:

0 - Zero chance of dozing
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Rate your chance of dozing during a traffic jam. Select one.

Sleep Study

There is an indication that you should have a sleep study done. Simple home-based sleep studies are available.

Your dentist will discuss this with you. You can also click on the image below to learn more.

HOME-BASED SLEEP STUDY:

- Yes, I am interested
- No, I am not interested
- No, I don't feel I need one

Would you like some information on how a home-based sleep study works?

SLEEP APNEA CLASSIFICATION:

- Severe
- Moderate
- Mild

What is your sleep apnea diagnosis?

SLEEP STUDY REPORT:

- I have a copy
- I do not have a copy
- Yes but I have to locate it

Do you have a copy of your sleep study report?

Sleep Study Report Needed

Please find the report and bring it with you for your upcoming consultation.

Sleep Study Report Needed

Please request a copy of the report and bring it with you for your upcoming consultation.

SLEEP APNEA RECOMMENDATION:

- My doctor has recommended treatment to treat my sleep apnea
- My doctor has not recommended treatment my sleep apnea

Has the doctor managing your sleep apnea recommended some treatment for your sleep apnea?

SLEEP STUDY REPORT:

Click or drag a file to this area to upload.

Upload your sleep study report, or take photos of the report and upload it here.

SLEEP APNEA DEVICE USE:

- Yes
- No

Are you using any devices, such as a CPAP, custom-fitted mandibular advancement, or over-the-counter stop-snoring device?

SLEEP APNEA DEVICE USED:

- CPAP
- Other device

What is the device you use to treat your sleep apnea and snoring?

OTHER SLEEP APNEA DEVICE:

Describe the other device you use to treat your sleep apnea and snoring.

CPAP USE:

- I have tried using a CPAP, but I am unable to wear it
- I do not like the idea of using one
- I use a CPAP, but I do not like wearing it
- I use a CPAP and have no problems with its use

How do you feel about wearing the CPAP? Select the best match answer.

Oral Snore/Sleep Apnea Appliance

If you do not like your CPAP machine or the idea of wearing one, we provide the custom-made oral device below with a satisfaction guarantee.

If unsatisfied with the result within three months, you will be entitled to a refund of 80% of your out-of-pocket costs for the treatment fee. We offer this trial because we are confident we can reduce your sleep apnea. This is how we ensure our patients are satisfied regardless of the outcome.

Click here to learn more about this Australian-made appliance.

OTHER HEALTH CONDITION:

- No
- Yes

Do you have any other health conditions that we have not covered above?

OTHER HEALTH CONDITION DETAIL:

What other conditions do you have? Please name the condition or give a brief description.

HOSPITILISATION:

- No
- Yes

Have you ever been hospitalised?

Hospitalisation

Listing hospitalisations to your dentist is crucial as it provides vital insight into your overall health status and any treatments or medications you may have received.

HOSPITILISATION HISTORY:

- Within the last twelve month
- More than twelve months ago

Have you ever been hospitalised?

RECENT HOSPITILISATION FOR:

What was the reason for your hospitilisation?

OTHER OPERATIONS/SURGERY:

- No
- Yes

Have you had any operations or surgery not listed above?

OPERATIONS DONE:

What was the operation, and what year did you have it done?

GENERAL ANAESTHETIC:

- No
- Yes

Have you ever had a general anaesthetic (put to sleep) for an operation or surgery?

GA - ADVERSE REACTION:

- No
- Yes

Have you ever had a bad reaction to the drugs used during your general anaesthetic?

DISABILITY:

- No
- Yes

Do you have any disabilities?

ORAL CARE IMPACT:

- No
- Yes

Does your disability affect your day to day oral hygiene activity?

MOBILITY AID:

- No
- Yes

Do you use a mobility aid?

ASSISTANCE NEEDED:

- I need assistance to transfer from my mobility aid to the dental chair
- I need to have my dental care done while I am on my mobility aid

Do you use a mobility aid?

Carer or Assistant Required

We apologise for any inconvenience this may cause. Still, due to Occupational Health and Safety (OHS) regulations, our staff cannot assist with transferring individuals from their mobility aids to the dental chair. Please bring a carer or assistant who can support the transfer to ensure your safety and comfort during the appointment. Your well-being is our top priority, and we appreciate your understanding and cooperation in this matter. If you have any questions or need further assistance, please contact us. Thank you for your understanding.

ALLERGY:

- Yes
- No

Are you allergic to anything?

Allergy Status

Declaring your allergies to your dentist is essential to prevent allergic reactions during dental procedures. This information allows your dentist to avoid potential allergens in treatments, choose suitable materials, and provide safe and personalised care tailored to your needs, ensuring a comfortable and risk-free dental experience.

DRUG ALLERGY:

- Yes
- No

Are you allergic to any medications or drugs?

DRUG ALLERGIES:

Select the drugs are you allergic to?

OTHER DRUG ALLERGY:

What is the Other Drug you are allergic to?

LATEX ALLERGY:

- Yes
- No

Are you allergic to latex?

NICKLE ALLERGY:

- Yes
- No

Are you allergic to nickle?

OTHER ALLERGY:

- Yes
- No

Are you allergic to anything else not already mentioned above?

OTHER ALLERGIES:

- Animal
- Food
- Stings
- Other

What other allergies do you have?

OTHER ALLERGY:

What are the other things you are allergic to?

ANIMAL ALLERGY:

What animals are you allergic to?

FOOD ALLERGY:

What Foods are you alergic to?

STING ALLERGY:

What are the Stings you are alergic to?

DENTAL MATERIAL ALLERGY:

- Yes
- No

Are you allergic to dental materials, such as amalgam, chromium, and composite resins...?

ALLERGY TO:

- Amalgam
- Chromium
- Composite Resin
- Other material

What dental materials are you alergic to?

OTHER DENTAL ALLERGY:

What is the dental material are you allergic to?

HAY FEVER:

- Yes
- No

Do you have Hay Fever?

HAY FEVER TREATMENT:

- Yes
- No

Are you taking any medication for Hay Fever?

HAY FEVER MEDICATION:

What medication or supplements are you taking for Hay Fever?

Other Medications

These items can harm oral health and influence our treatment plan to optimise it.

CHOLESTEROL TREATMENT:

- Yes
- No

Are you taking any cholesterol-lowering medications?

CHOLESTEROL MEDICATION:

What Cholesterol-lowering medication or supplements are you taking?

WEIGHT LOSS MEDICATION USE:

- Yes
- No

Are you taking weight loss medication or supplements?

WEIGHT LOSS MEDICATION TYPE:

Name of any weight loss medication or supplements being taken.

OTHER MEDICATIONS:

- Yes
- No

Are you taking other prescription medications, supplements, inhalers, and over-the-counter medicines not already listed above?

OTHER MEDICATION TAKEN:

- None
- Prescription medication
- Non-prescription medication
- Alternative medications or supplements

Do you take other prescriptions, supplements, or alternative medicines you may not have listed in the previous sections? Select all that apply.

OTHER PRESCRIPTIONS:

What other prescription medications are being taken that you have not already declared above?

OTHER MEDICATION FOR:

Why are you taking the other prescription medication?

OTHER MEDICATIONS FORMS:

In what form are these non-prescription, supplements or alternative medicines being taken?

EYE DROPS:

What Eye Drops are you taking? Please write the name of the medicine, dose, and frequency of use.

EAR DROPS:

What Ear Drops are you taking? Please write the name of the medicine, dose, and frequency of use.

INHALLERS | PUFFERS:

What Inhallers or Puffers are you taking? Please write the name of the medicine, dose, and frequency of use.

CREAMS | OINTMENTS:

What Creams or Ointments are you taking? Please write the name of the medicine, dose, and frequency of use.

TABLETS:

What Tablets are you taking? Please write the name of the medicine, dose, and frequency of use.

Recent Medication

Informing your dentist about recently discontinued medications is crucial, as certain drugs can have lingering effects or interact with dental treatments.

RECENTLY CEASED MEDICINE:

- No
- Yes

Have you taken and stopped any prescription, non-prescription, alternative medicines or supplements in the last two months?

MEDICATION RECENTLY CEASED:

Select all that apply.

PAINKILLER:

Please write the name of the Painkiller you recently stopped taking, the dose, and the frequency of use.

ANTIBIOTIC:

Please write the name of the Antiobiotic you recently stopped taking, the dose, and the frequency of use.

REFLUX MEDICINE:

Please write the name of the Reflux medication you recently stopped taking, the dose, and the frequency of use.

SLEEP MEDICINE:

Please write the name of the Sleep medication you recently stopped taking, the dose, and the frequency of use.

DRY EYE MEDICINE:

Please write the name of the Dry Eye medication you recently stopped taking, the dose, and the frequency of use.

DRY MOUTH MEDICINE:

Please write the name of the Dry Mouth medication or product you recently stopped taking, the dose, and the frequency of use.

CONSTIPATION MEDICINE:

Please write the name of the Constipation medication you recently stopped taking, the dose, and the frequency of use.

OTHER MEDICINE:

Please write the name of the Other medication you recently stopped taking, the dose, and the frequency of use.

MEDICATION LIST:

- No
- Yes

Do you have a document listing all the medicines you take?

MEDICATIONS LIST:

Click or drag files to this area to upload. You can upload up to 5 files.

You can take photos of the medication list or upload the list here.

Recreational Substances

These substances can have lingering effects on oral health and may impact the success of dental treatments.

SUBSTANCE USE:

- No
- Yes
- Yes but I have stopped
- Rather not say

Have you ever taken any recreational substances such as marijuana, cocaine, ecstasy, MDMA…?

STOPPED:

Write the name of the recreational substances recently taken & stopped.

ONCE USED:

Write the name of these recreational medications or drugs once taken.

Vaccination Status

The dentist must know your vaccination status to ensure appropriate preventive measures and customise treatment plans based on your immunity to infectious diseases, promoting optimal oral health care.

VACCINATION:

- All are up-to-date
- I am an anti-vaxer
- Some are up-to-date
- Rather not say

Are you up-to-date with your vaccinations such as dTpa, Influenza B, Hepatitis B, Rotavirus, Yearly-Influenza (Flu), Meningococcal ACWY and Phenumoccal?

dTpa VACCINE:

- No
- Yes

Is your Diphtheria, Tetanus and Pertussis vaccination up-to-date? Normally administered to children at ages 2,4,6 and 18 months and 4 yrs. Adolescents at age 12-13

INFLUENZA B:

- No
- Yes

Is your Haemophilus influenzae type B vaccination up-to-date:? Normally administered to children at ages 2,4,6 and 18 months and 4 yrs.

HEPATITIS B:

- No
- Yes

Is your Hepatitis B vaccination up-to-date? Normally administered to children at ages 2,4,6 months.

POLIO:

- No
- Yes

Is your Polio vaccination up-to-date? Normally administered to children at ages 2,4,6 months.

ROTAVIRUS:

- No
- Yes

Is your Rotavirus vaccination up-to-date? Normally administered to children at age 4 months.

MEASLES, MUMPS & RUBELLA:

- No
- Yes

Is your Measles, mumps, rubella or varicella vaccination up-to-date? Normally administered to children at age Children 12 and 18 months.

INFLUENZA (FLU):

- No
- Yes

Is your Influenza vaccination up-to-date? Normally administered annually March to June.

MENINGOCOCCAL ACWY:

- No
- Yes

Is your Meningococcal ACWY vaccination up-to-date? Normally administered to Children 12 months and Adolescents ages 14-16 years.

HUMAN PAPILOMA VIRUS:

- No
- Yes

Is your Human Papilloma Virus vaccination up-to-date? Normally administered to Adolescents ages 12-13 years.

PNEUMOCOCCAL:

- No
- Yes

Is your Pneumococcal vaccination up-to-date? Normally administered to Children 2 months, 4 months, 12 months. Children at risk 4 yrs. All adults over 65. Aboriginal and Torres Straight Islanders over age 50 years.

SHINGLES:

- No
- Yes

Is your Shingles vaccination up-to-date? Normally administered to Adults age over 70 years.

OCCUPATION

ALCOHOL DRINKER:

- Yes
- No

Have you ever consumed alcohol?

Declare Alcohol Use

Alcohol interacts with various medications and treatments, affecting their efficacy and safety.

ALCOHOL CONSUMPTION:

Please select the option that best describes your alcohol consumption.

WHEN:

When did you quit drinking alcohol?

SMOKING OR VAPING:

- Never
- Quit
- Currently smoking or vaping
- Want to quit

Have you ever smoked or vaped?

SMOKING OR VAPING ON:

- Social occasions only
- Every day
- Rarely

What is your smoking or vaping pattern?

WHEN:

When did you quit smoking or vaping?

HELP WITH QUITTING:

- Yes
- No
- Maybe

Would you like us to help you access some resources to help you quit smoking?

Declaring Accuracy!!!

Declaring the accuracy of the medical history provided is vital for proper treatment, informed decisions, and patient safety.

If you think you may have answered incorrectly, please scroll back and edit the response before clicking the Next button.

Declaring Authority!!!

Declaring authority is compulsory when completing a medical history form for someone else.

Declaring the accuracy of the medical history provided is vital for proper treatment, informed decisions, and patient safety.

If you provided an incorrect answer, please scroll back and edit the response before clicking the following button.

CARER AUTHORITY DECLARATION:

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and tick all statements to verify your agreement. Then, tick the last checkbox if you feel the dentist should clarify some answers.

PARTNER AUTHORITY DECLARATION:

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and tick all statements to verify your agreement. Then, tick the last checkbox if you feel the dentist should clarify some answers.

FOSTER CARER AUTHORITY DECLARATION:

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Read all statements to verify you agree. Then tick the last checkbox if you feel some answers need to be clarified by the dentist.

GUARDIAN AUTHORITY DECLARATION:

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and tick all statements to verify your agreement. Then, tick the last checkbox if you feel the dentist should clarify some answers.

PARENT AUTHORITY DECLARATION:

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and tick all statements to verify your agreement. Then, tick the last checkbox if you feel the dentist should clarify some answers.

PATIENT DECLARATION:

- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and tick all statements to verify your agreement. Then, tick the last checkbox if you feel the dentist should clarify some answers.

Signature

Clear Signature

$10 Credit for Form Feedback

Claim your $10 reward for helping us improve this form.

FORM FEEDBACK:

- Yes, I claim the $10 credit
- Not interested in providing feedback

$10 credit for helping us develop this form. It can take up to 60 seconds to give the input.

FORM CONVINIENCE RATING:

1-Star very inconvient. 7-Stars for Totally convient.

FORM USER-FRIENDLY RATING:

1-Star not user-friendly. 7-Stars for Very user friendly.

FEEDBACK STATEMENT:

I had some difficulty completing the form,
Submitting my medical history online was convenient and saved me time in the Practice waiting room!
Completing my medical history online allowed me to provide detailed information at my own pace.
Without a doubt, I find filling out the medical history form online to be the most accurate and efficient method, significantly reducing the need for paperwork during my visit.
I prefer to fill out the medical history form during my visit.

Select the statement that best represents your experience in completing this form.

FORM COMMENT:

Please provide positive or negative feedback on your experience in completing this form.

Medical Questionnaire

PLEASE NOTE!

Gender Hormones

Questionnaire Completed By

Health Questionnaire

Heart Conditions

Critical Health Information Required!

Blood Pressure Conditions

Liver Disease

Kidney Conditions

Bone Disease

Gastrointestinal, Stomach or Digestive Conditions

Lung Disease

Mental Health

Headaches

Dental Care & Neurological Conditions.

Blood Conditions

Stroke

Blood-Borne Viruses

Immune Condition

Cancer

Thyroid Conditions

Eye Conditions

Skin Conditions

Sleep

Sleepiness Check Needed!

Sleep Study

Sleep Study Report Needed

Sleep Study Report Needed

Oral Snore/Sleep Apnea Appliance

Hospitalisation

Carer or Assistant Required

Allergy Status

Other Medications

Recent Medication

Recreational Substances

Vaccination Status

Declare Alcohol Use

Declaring Accuracy!!!

Declaring Authority!!!

$10 Credit for Form Feedback

Understanding Your Medical History

A Medical Histtory is Essential for Safe Effective Dental Care_READ MORE

Medical & Medication History

Guarding Patient Confidentiality: A Top Priority

Patient Confidentiality_READ MORE

Patient Confidentiality

About Riverina Dental