Download – Adult Medical History Questionnaire

Welcome to our Dental practice,
Our aim will be to offer you a complete, thorough and personalised dental treatment, in a pleasant and comfortable
atmosphere, with special emphasis on preventive dentistry and control of pain and apprehension. A thorough examination, for
your welfare, protection and comfort, requires full knowledge of your dental and medical history, and some understanding of
your personal feelings.
So that we may serve you better, we ask you to complete the following questionnaire as accurately as possible. All information
will, of cause, be treated with the utmost confidence. Thank you
Title………Surname…………………………...…….First……………..……Pref Name………………….
Medical History
Are you presently receiving Medical Treatment? Yes/No If so, what for? …………………………….
Are you taking any drugs, medicines or pills prescribed by GP or alternative medicines? – If yes please
list ……………...............................................................................................................................................
……………………………………………………………………………………………………………….
Who is your Medical Practitioner? Dr………………………………………Town:………………………...
Do you have, or ever had, any of the following? – please tick or circle relevant options
Heart problems/heart surgery
•
Hepatitis A, B, C or HIV (Aids)
•
Heart Murmurs/False Heart Valves
•
Intravenous drug use
•
Pacemaker
•
Osteoporosis
Previous Antibiotic cover for Dental Treatment • Stomach Ulcer
•
Low / High blood pressure
•
Blood transfusion(s)
•
Rheumatic Fever
•
Diabetes / Delayed Healing / Epilepsy
•
False joints (ie Hip, Knee)
•
Nerves/ Psychiatric Treatment
•
Excessive Bleeding/ Bruising
•
Cobalt Treatment/ Radiotherapy
•
Anaemia or Blood Disorders
•
Kidney Disorders / Ankle swelling
•
Emphysema, Chronic Cough, TB
•
Ladies: If pregnant, how many months? …….……..
Dizziness or Fainting
•
Lung Problems
•
Are you a smoker?
Yes/No
Heart attack, Heartburn, Asthma, Hay Fever, Pressure or Tightness in chest, Bronchitis, Sinus, Jaundice
Any other serious illness? .......................................................Major Surgery…………………………..
Are you allergic to: Antibiotics/ Penicillin - • Codeine - • Morphine - • Pethidine - • Aspirin - •
Jewellery or metals - • Other drugs/ Medicines …………………………………………………………
Have you had a General Anaesthetic?
Yes/No
Did you have any problems?
Yes/No
Do you have Skin Allergies?
Yes/No
Do you wear Contact Lenses?
Yes/No
Is there anything you would like to discuss with the dentist confidentially?
Yes/N
Are you presently having dental pain?
Yes/No If so, where? ……………………………………
Are you comfortable during Dental Visit? Yes/No When was your last exam?………………………
Do any of the following worry you? Noise - • Injections - • Other (please specify) …..……………
For dental treatment do you usually have:- Local Anaesthetic • Happy Gas • IV • or
General Anaesthetic •
What do you specifically want me to do for you?…………………………………………………………..
It is our policy to charge a $40 fee if you fail to attend a confirmed appointment.
I have completed the above accurately and truthfully to the best of my knowledge
Signed……………………………………
Date……………………
PTO…
General Information
Address…………………………………………………………………….................Post code...………….
Date of Birth……………… Phone - H: ……………….W: ………………….. Mob:……………………..
EMAIL: ……………………………………………………………………………………………………..
Occupation:…………………………………………… Employer:………………………………………..
Name of Spouse/Partner…………………………Occupation:…………………… Ph:…………………….
Person responsible for fees ………………………………………………………...Ph:…………………….
Dental Health Fund ...........................................Membership Number …………………………….
Series Number (Located next to your name on the card)…………………………………………...
If referred to this practice, whom may we thank? ………………………………………………………….
Dental History
How often do you brush your teeth?…………………How Long?…….Secs
Do you floss? - Yes /No
Have you had professional instruction? - Yes/No
Are you prone to any of the following? (please circle )
Bleeding, Swollen, Tender Gums/Bad Breath/ Bad Taste.
Food catching between your teeth/ Teeth difficult to get numb, even with a number of injections/ Teeth
sensitive to hot, cold or pressure.
Difficulty swallowing/ easily gag.
Do you have un-replaced missing teeth?
Yes/No
Are you dissatisfied with your teeth and/or their appearance?
Yes/No
Do you always have something to be treated or repaired when you visit a Dentist?
Yes/No
Are you concerned about the finances required to return your mouth to good health?
Yes/No
Do you feel you will eventually have to wear Full Dentures? Yes/No
What age? …………..
Denture Wearers, do you have a denture problem?
Yes/No
If Yes, is it ….
• Appearance
• Function
• Pain
• Discomfort
Occlusal Screening - Assessing for Traumatic Bite
Do you clench or grind your teeth?
Yes/No
Do you have sinus headaches?
Yes/No
Do you have an uncomfortable bite?
Yes/No
Do you have tight, stiff neck muscles? Yes/No
Do you have clicking jaw joints?
Yes/No
Do you ever wake up with vague ache or awareness of your teeth or joint muscles, as if you’ve had them
clenched?
Yes /No
• Right • Left • Both
Do you have chronic headaches, neck and shoulder pain?
Yes/No
Do you now, or have you ever had, pain in your jaw, sides of your face?
Yes/No
Which side do you chew on? Left/Right
Dietary Habits - Caries Risk
Do you eat (or drink) any of the following on most days:
• Sweets
• Carbohydrates (Biscuits, cakes etc) • Soft Drinks
• Fruit
• Sweetened tea/coffee
• Honey
• Sugar coated cereals
• Between - meal snacks
Thank you for your time, and we appreciate your kind co-operation.
For your safety, if your condition should change, please volunteer the information to us.