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 ProblemsYesNo
Blood PressureYesNo
Artificial JointsYesNo
Rheumatic FeverYesNo
Circulatory ProblemsYesNo
Radiation TreatmentYesNo
Excessive BleedingYesNo
Excessive BruisingYesNo
Ulcers (stomach)YesNo
Sinus TroubleYesNo
Artificial Heart ValvesYesNo
Infectious DiseasesYesNo
Allergies to AnaestheticsYesNo
Allergies to PenicillinYesNo
Allergies to MedicationsYesNo
Allergies to LatexYesNo
Anaemia or other Blood DisordersYesNo
Liver or Kidney ProblemsYesNo
Tumour/Cancer HistoryYesNo
Hormone Replacement TherapyYesNo
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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