Lane Cove NSW 2066

Appointments & questions

New Patient Form

    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

    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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