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New Patient Health History Form
Please complete this form so we can provide you with safe dental treatment of the highest standard. Please tick
all applicable boxes below.
Dr First name __________________________________Family name _____________________________________________
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____________________________________________________Suburb ____________Postcode
Phone: H _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ W _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Mob _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth ______/______/_______
Occupation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Email _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
How did you learn about us?
(Please let us know the name of your friend or family member so that we can say “thank you”) _______________________________________________ Preferred method of contact for appointment reminders:
MEDICAL HISTORY
Doctor’s name ____________________________________________ Phone no. ______________________________________________
Current medical treatments _________________________________________________________________________________________
Current medication e.g. Warfarin, Fosamax, Aspirin, HRT________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________ Allergies e.g. Penicillin _______________________________________________________________________________________________
HAVE YOU SUFFERED ANY OF THE FOLLOWING? Please provide details
Heart complaint:
_____________________________________________________________________________________________________________________________________________________________________ Arterial disease:
Other __________________________________________________________________________ Blood disease:
Other _________________________________________________________________________________ Rheumatic fever
Tuberculosis
Hepatitis A, B or C
Diabetes
Auto-immune diseases
Asthma/Sinus
Epilepsy
Excessive bleeding
Artificial prosthesis
Other ________________________________________
Are you pregnant?
Have you had radiation therapy?
Have you had any other serious illness or surgery?
Treatment / illness details _____________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________ DENTAL HISTORY
How long since your last dental examination? ________________________________________________________________________
Do you have any concerns regarding your dental health? ______________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________ Have you had any previous problems associated with dental treatment? _______________________________________________
___________________________________________________________________________________________________________________ I understand that payment is due at the time of service unless other arrangements have been made.
Signed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date ________/________/_________
Chatswood Dental Care, Mezzanine Level/Gallery Arcade, Shop 11, 445 Victoria Ave, Chatswood NSW 2067 (02) 9412 2295 [email protected] www.chatswooddentalcare.com.au

Source: http://www.chatswooddentalcare.com.au/site/DefaultSite/filesystem/documents/CDC_New_Patient_Health_History_form.pdf