Medical History Questionnaire

Please fill out the Medical History Questionnaire prior to your first appointment with us at Kooringal Dental. If you cannot fill it out online, please find a copy of the questionnaire here.

If you are in pain, broke your tooth or have any urgency, please call us on (02) 6922 6840

The following questions are in regards to your personal details and medical history. These questions are designed to identify factors that may influence the delivery of your dental care. All personal information is treated with complete confidentiality and in accordance with the Privacy Act 1988. Please ask Reception if you would like to access the Privacy Policy.

Personal Details

Salutation*:

Private Health Insurance* YesNo

If under 18 only - Medicare details:

Do you have a Pension or Healthcare Card?* YesNo

How did you find out about Kooringal Dental?*:

If you were referred by an existing patient, please write the name of the referrer:

Any of your immediate family attend our practice? If yes, family name?:

Do you have any concerns about your dental health? Or anything about your smile you want to change? If yes, what are they?*

How would you like to be contacted for appointments?* (check all applicable) SMSPhone call

Confidential Medical History

The state of your health may have a significant effect on your dental care. It's important to answer the below questions as completely and honestly as possible.

Please indicate if you have any of the following:

How long since your last dental appointment?*

What medical practice do you attend? What's their phone number?*:

Rheumatic Fever:	YesNo
Pacemaker:	YesNo
Heart (Cardiac) Issues:	YesNo
Heart (Cardiac) Surgery? Year:	YesNo
Heart condition: Murmur/Angina?	YesNo
Heart condition: Family history under 65 years old?	YesNo
Are you taking blood thinning medication?	YesNo
Cancer: If yes, which type?:	YesNo
Currently undergoing Chemotherapy?:	YesNo
Currently undergoing Radiation?:	YesNo
Osteoporosis or low bone density:	YesNo
Taking any medications for osteoporosis?:	YesNo
Asthma, hay-fever or sinus? If yes, please specify:	YesNo
Dizziness/fainting?	YesNo
Diabetes: If yes, which type?:	YesNo
Diabetes: Family history under 65 years old?	YesNo
Hepatitis: If yes, which type?:	YesNo
Immune system disorder?	YesNo
Allergies to any food or substances: If yes, what?:	YesNo
Adverse reactions to local or general anaesthetic?:	YesNo
Are you allergic to latex?:	YesNo
Are you allergic to any medication?:	YesNo
Have you had a difficult tooth extraction?:	YesNo
Before dental treatment, are you required to take antibiotic prophylaxis?:	YesNo
Blood Disorder:	YesNo
Tuberculosis:	YesNo
HIV-positive:	YesNo
Depression or other mental illness?:	YesNo
Anxiety Disorder?:	YesNo
Epilepsy:	YesNo
High/Low Blood Pressure:	YesNo
Nervous System Disorder:	YesNo
Jaundice or Liver Disease:	YesNo
Thyroid Disease (including Goitre):	YesNo
Dry Mouth:	YesNo
Snoring:	YesNo
Sleep Apnoea:	YesNo
If yes, do you use a CPAP Machine?:
Gastric Ulcer:	YesNo
Gastric Disorder/Reflux?:	YesNo
Surgery in last 6 months?:	YesNo
Are you pregnant?	YesNo
If yes, please specify your due date:
Currently breastfeeding?:	YesNo
Undergone Joint Surgery?:	YesNo
If yes, which joint?:
If yes, which year?:
Currently on any medication?:	YesNo
If yes, which medications?:
Any other medical conditions?:
Do you smoke?:	YesNo
If yes, for how many years and how many per day?:

Agreements

I understand that failure to complete the medical history information completely and honestly may place myself and others at medical risk.*

I have accurately completed this medical history form to the best of my knowledge.*

I hereby give my authority for any treatment agreed upon by me, to be carried out by the Dentist and their support team, and I assume full financial responsibility for said treatment.*

I understand that I am signing in agreement to this by pressing submit.*

I would like to be kept informed of information regarding current and new services, new or updated practice information, and dental techniques that may affect my next visit.

Medical History Questionnaire

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Kooringal Dental in Wagga Wagga

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