Medical and Dental History Form

Medical and Dental History Form

At Lightsview Dental, we consider it important to know about your medical/dental history, before we plan your dental treatment, in order to ensure that we provide this treatment to you in a safe way.
The information in this form is confidential, and will be handled in accordance with our privacy policy which you can find on the last page of the form.

First Name:*

Last Name:*

Date of Birth:*

Address:*

Suburb:*

Postcode:*

Phone (home):

Phone (work) :

Phone (mobile):*

Email*:

Occupation:*

How would you like to be contacted for appointment reminders?
SMSEmailPhone callNone

How would you like to receive your 6 Monthly Check-up reminders?
SMSEmailLetterNone

Name of emergency contact person:*

Phone of emergency contact person:*

Name of your medical practitioner:*

Phone of your medical practitioner:*

How did you hear about us?
InternetDirectoryPatient

If patient, Name of the Patient:

Do you have private health insurance with dental cover? If yes, which one?

Are you taking any prescription or herbal medication or supplements?
YesNo

Do you normally require antibiotic cover before dental treatment?
YesNo

Have you had any abnormal reactions to local or general anaesthesia?
YesNo

Do you smoke?
YesNo

Are you or could you be pregnant?
YesNo

Are you being treated by a doctor at present?
YesNo

Have you been hospitalised in the last 12 months?
YesNo

Have you or anyone in your household returned from overseas travel in the last 10 days?
YesNo

Is snoring a problem for you or your partner?
YesNo

Has anyone heard you stop breathing or do you gasp or choke during sleep?
YesNo

Are you sleepy during the day?
YesNo

Do you wake feeling unrefreshed?
YesNo

Have you had a sleep study done?
YesNo

Have you ever had orthodontic treatment?
YesNo

Are you aware of any clenching or grinding of your teeth?
YesNo

Do you notice any problems with chewing or jaw movements?
YesNo

How long ago was your last dental visit?
less than 1 yearmore than 1 year

Have you had dental xrays in the last 2 years?
YesNo

Please list all known allergies (including drugs, latex, foods & preservatives):

Please list all medications you are taking (prescription, herbal, supplements)

Do you have now, or have you ever had, any of the following medical conditions? (Please tick any you have or had)
AsthmaStrokeLow blood pressureBronchitis, emphysema or other lung diseasesEpilepsyCardiac pacemakerHepatitis or other liver diseasesSteroid therapyStomach or digestive conditionAnaemia, leukaemia or other blood diseasesKidney diseaseProsthetic implant e.g. artificial hip/kneeHigh blood pressureTuberculosisDiabetesHeart disorder/complaintThyroid diseaseCancerRheumatic feverExcessive bleedingRadiation therapyNervous/psychiatric conditionContact with blood-borne virusesBone diseaseOsteoporosisGastric Reflux

Any other condition (please list)

Reason for dental appointment?

Privacy Policy in regards to medical/dental history form

At Lightsview Dental, we respect your privacy.
In order to provide you with the highest standard of dental care, our practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary for the dentist to obtain from you details regarding your general health and past medical or surgical events. Without this general health picture, the treating dentist is unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be unnecessarily disclosed to others. We value the need to safeguard this information and in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

• This information will only be used by the treating dentist in order to deliver your care to the highest standards.

• This information will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information.

• You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.

• There will be no charge made for requesting this information but there may be fees levied just to cover the cost associated with the processing of this request or the copying of information.

• We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date.

• We will take reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure.

• Our staff is trained to respect these principles at all times.

• If you have any questions in regards to the information we collect from you, please do not hesitate to ask us.

I read and accept the ‘Privacy Policy’ on this form.

Date: