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Patient Information & Medical History

At Kylie’s Family Dental Practice we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

    Personal Information

    Title:

    Surname:*

    First Name:*

    Preferred Name:

    Date of Birth:*

    Address:*

    Suburb / Town:*

    Postcode:*

    Home Phone:

    Mobile Phone:*

    Work Phone:

    Your Email:*

    Occupation:*

    Employer:

    Next of Kin

    Name:

    Relationship:

    Phone:

    Medical Information

    Medicare Number:*

    Position on Card:*

    Expiry Date:*

    Private Health Fund (if any):*

    Private Health Fund Number:

    Private Health Fund Position on Card:

    Do you have extras cover?:*
    YesNo

    Dept. Veteran Affairs (DVA):
    YesNo

    DVA Card No:

    DVA Expiry Date:

    Dental History

    How long since your last dental examination?

    Please outline any dental concerns you have:

    Are you interested in teeth whitening?
    YesNo

    Do you snore or experience restless sleep?*
    YesNo

    Do you experience jaw pain or discomfort?*
    YesNo

    Current Smoker?*
    YesNo

    If yes, how many per day?

    Previous Smoker?*
    YesNo

    How long since you have quit?

    Are you of Indigenous, Torres Strait Islander or South Sea Islander heritage?*
    YesNo

    Reminders


    We'd like to remind you about your upcoming appointments. Please select the most convenient form of contact:*

    SMSMobileHome PhoneWork PhoneEmail

    Medical History

    Who is your General Practitioner?

    Phone:

    Have you had, or are you suffering from any of these conditions? Please indicate Yes or No for each.


    Heart Complaint: YesNo


    Hepatitis: YesNo


    HIV Positive: YesNo


    Asthma: YesNo


    Blood Pressure: YesNo


    Oral Cancer: YesNo


    Bisphosphonates e.g Fosamax, Denosumab (Prolia) Injection: YesNo


    Chemotherapy / Radiation: YesNo


    Diabetes: YesNo


    Osteoporosis: YesNo


    Osteoarthritis: YesNo


    Epilepsy: YesNo


    Congenital Heart Defect: YesNo


    Rheumatic Heart Disease: YesNo


    Blood Thinning Medication: YesNo


    Nervous Disorder / Anxiety / Depression: YesNo

    Any other conditions:

    Are you currently pregnant?*
    YesNo
    If yes, how many weeks?

    Have you had surgery in the past 6 months?*
    YesNo

    If you have had surgery in the last 6 months, list the procedure(s) below:

    Please list any medications you are taking, including medication name and strength, dose taken - quantity and when taken, duration of use and purpose.This includes prescribed and over the counter medication that you are taking, including non-oral (Eg; Eye Drops, Inhalers, injections, COVID-19 vaccination etc)

    Please list any allergies to drugs, foods or materials, including name, nature of reaction and when reaction occurred:

    Consent for Services

    Ticking the following box certifies that I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.
    *Yes

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