About You


First Name (required)


Date of Birth




Post Code

Phone (Home)

Work Phone


Email (required)


Health Fund

Emergency Contact

If you are under 16, please name a parent/guardian

Your Medical History

Have you ever had any of the following? Please tick those that apply:

 High/Low Blood Pressure Rheumatic Fever Allergies or Hives Arthritis Stroke Emphysema Bleeding Disorder Heart Surgery/Attack
 Epilepsy Diabetes Hepatitis A, B, C Anaemia Contact with HIV/AIDS Stomach Ulcers Thyroid Disease Liver Disease
 Artificial Joint Heart Complaint Asthma or Breathing Problems Steroid Therapy Kidney Disease Tuberculosis Sinus Therapy Cancer

Who is your usual GP?



Are you currently taking any medication?

Are you currently undergoing medical treatment?

Do you smoke?

Ladies, are you pregnant?

If yes, when are you due

Are you allergic to any medication or materials? i.e Penicillin. Latex?

Is there anything else you would like to tell us about your general health?

Your Dental Health

What brings you to our practice today?

When was your last dental visit?

Please tick any dental concerns that you have:

 Toothache Missing Teeth Face or Jaw Pain Loose Teeth
 Sensitive Teeth Denture Problems Worn or Broken Teeth Bleeding Gums
 Lost or Loose Filling Difficulty Chewing Grinding or Clenching Teeth Discoloured Teeth

Do you feel nervous about your dental treatment?

 No Slightly Moderately Extremely

Do you usually require antibiotics before dental treatment?

Have you ever had any adverse reaction to dental treatment?

Have you had your wisdom teeth removed?

Are you interested in whitening or cosmetic treatment?

How did you hear about us?

 Internet/Website Radio Flyer/Mail out
 Health Fund Newspaper Tooth Fairy Visit
 Signage Referral Other

If you were referred here today, whom can we thank?