New Patient Form

Name: Apple Dental
Address: 1/1 Finlayson St, Lane Cove, NSW, 2066, AU
Telephone: (02) 9420 5050

Salutation:

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