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Client Medical History Questionnaire

Welcome to Ballina Coast Dental. In order to provide you with complete quality care we need to know about your state of
health and medical history. All information provided will be treated in strictest confidence, but if you are more comfortable
discussing personal matters with the dentist, then please do. Thank you.

First Name

Last Name

Home Address

Address Line 1

Address Line 2

City

State

Post Code

Country

Postal Address

Address Line 1

Address Line 2

City

State

Post Code

Country

Phone Number - Mobile

Emergency Contact

Date of Birth

Phone Number - Work

Employer

Confirm your future appointments by

Phone

SMS

Health Fund

Phone Number - Home

Occupation

How did you find out about our practice?

PAST / CURRENT MEDICAL CONDITIONS

Osteoporosis

Prosthetic joints or Heart valves

Blood pressure HIGH LOW (please circle)

Heart trouble

Rheumatic Fever

Hepatitis A B C (please circle)

HIV

Tuberculosis

Diabetes

Epilepsy

Jaundice

Asthma (bring puffer to appointments)

Anaemia

Arthritis

Other

CURRENT MEDICATIONS – please list

ALLERGIES – please list

(Women) Are you pregnant now?

Yes

DENTAL INFORMATION – please tick those that apply

Do you have a specific problem that you would like to discuss?

Yes

Would you like us to discuss how to whiten your teeth?

Yes

Do you have teeth that are sensitive to hot or cold?

Yes

Do you have pain in the jaw joints or suffer from headaches or migraines?

Yes

Do you have bleeding gums?

Yes

Do you have difficulty chewing?

Yes

Are you concerned with the appearance of your teeth?

Yes

Please notify us at least 24 hours in advance if you need to cancel your appointment. Failure to do so may incur a fee.

Payment of fees is to be made at the time of treatment.

Signature

Sign Here

Date

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Contact

Email: reception@ballinacoastdental.com.au Address: 56 Tamar Street, Ballina, NSW 2478 Phone: (02) 6686 3810

Client Medical History Form

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