Lane Cove NSW 2066

Appointments & questions

Medical History Questionnaire


    Dental Insurance YesNo

    Is another member of your family a patient at our office YesNo

    Any Heart Problems YesNo
    Blood Pressure YesNo
    Artificial Joints YesNo
    Rheumatic Fever YesNo
    Circulatory Problems YesNo
    Radiation Treatment YesNo
    Excessive Bleeding YesNo
    Excessive Bruising YesNo
    Ulcers (stomach) YesNo
    Sinus Trouble YesNo
    Artificial Heart Valves YesNo
    Infectious Diseases YesNo
    Allergies to Anaesthetics YesNo
    Allergies to Penicillin YesNo
    Allergies to Medications YesNo
    Allergies to Latex YesNo
    Anaemia or other Blood Disorders YesNo
    Diabetes YesNo
    Asthma YesNo
    Hepatitis YesNo
    Epilepsy YesNo
    Liver or Kidney Problems YesNo
    Tumour/Cancer History YesNo
    Hormone Replacement Therapy YesNo
    Are you currently taking any drugs or medicines? YesNo
    Does your jaw "click" or hurt? YesNo
    Do you feel you grind your teeth? YesNo
    Have you ever had orthodontic treatment? YesNo
    Do you wear a dental night guard? YesNo
    Have you ever had periodontal (gum) treatment? YesNo
    Have you ever had your bite adjusted? YesNo
    Do you bite your lips or cheeks often? YesNo
    Do you smoke? YesNo
    Do you think you have occasional bad breath? YesNo
    Do your gums ever bleed when you clean your teeth? YesNo
    Do you experience sensitivity with hot/cold? YesNo
    Do your teeth ever hurt when you bite hard? YesNo
    Does floss ever tear between your teeth? YesNo
    Does food get jammed between your teeth? YesNo
    Is there anything else you would like us to know? YesNo

    Are you pregnant? YesNo

    How long since your last dental appointment?

    How often do you have dental examinations?

    Previous dental x-rays were taken Less than 1 yearMore than 1 year

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