New Patient Medical and Dental History Form

NEW PATIENT MEDICAL AND DENTAL HISTORY FORM

Please note that all information on this medical/dental form will remain confidential. Please complete in CAPITAL LETTERS.

Appointment date _ _ / _ _/ _ _

Patient details

Mr/Mrs/Miss/Ms/DrLast Name: ______

First Name: ______Preferred Name:______

Tel. Home: _(_____)______Tel. Work: _(_____)______

Tel. Mobile:_(____)______E-Mail:______

Patients Address

______No Street City State Post Code

Date of Birth: ______Age:______Occupation:______

Emergency contact

Name:______Relationship: ______Phone number:_(___)______

Referring Dentist or Referral Source

Dentists name: ______Dentist Tel. No:______

Tooth # Area to be treated: ______1st Time treatment Re-treatment of a previous Root Canal Evaluation. Other:

Medical History

Name of your GP: ______Your GP’s Phone No:_(____)______

GP’s address (or suburb):______

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

High/Low blood pressure
Excessive bleeding, anemia or another blood disorder
Asthma or other respiratory problems (such as Chronic Obstructive Pulmonary disease/Emphysema/Bronchitis)
Hear Murmurs
Prosthetic heart valve
Pacemaker
Mitral Valve Prolapse
Congenital Heart Lesions
Rheumatic Fever
Hepatitis A, B, C
Fainting or dizziness
Diabetes
Sinus trouble
HIV/AIDS
Liver disease
Kidney disease
Jaundice
Joint or organ replacement
Cancer, chemotherapy or radiation Therapy
Stroke, seizures or epilepsy
Neurosurgery or neurological disorders
Anxiety or psychological disorders
Other:

Please indicate if you are allergic to any of the following

Aspirin: Yes No Codeine: Yes No Penicillin: Yes No

Local Anesthetic (Novocain): Yes No

(Women) Are You:

Pregnant Now? Yes No

Nursing? Yes No

Taking Birth Control Pills?Yes No

List any other drugs or medications you cannot take or are allergic to:

Are you currently on Bleomycin sulfate (used in cancer treatments)? Yes No

List any drugs or medications you routinely take:

Have you been hospitalized in the last two years? Yes No

Does dental treatment make you nervous?No / Slightly / Moderately / Extremely

Have you ever had the following for dental treatment?

Gas (Nitrous oxide/laughing gas)Yes No Intravenous sedation Yes No

General AnesthesiaYes No

CONSENT FOR SERVICES

I, the undersigned, consent to the performing of endodontic procedures agreed to be necessary or advisable, including the use of local anesthetics and/or nitrous oxide as indicated and I will assume responsibility for the fees associated with those procedures.

I am aware that full payment is required on the day of treatment.

I am aware that my health insurance policy will determine my eligibility and the rate of refunds for this treatment.

I understand that the practice requires at least 48-hours notice if I need to cancel my scheduled appointment and that a cancellation fee of $50.00 could be incurred if I fail to do so.

I hereby consent the use of my x-rays, computer images and photographs may be sent to other dental practitioners (to aid with my treatment) or may be used at various dental or endodontic seminars, lectures, and publications that the endodontist may author.

I have completed this questionnaire to the best of my knowledge and understand that failure to make full disclosure may place me at undue medical risk.

Patients Signature:______Date:______

Please print and bring with you to your appointment