Medical History Form

Welcome to our practice. The following information is requested to enable us to give you our best care. Each question is relevant to modern medical and dental practice. All information will be kept in accordance with The Privacy Amendment (Private Sector) Act 2000. A copy of Mr Player’s Privacy Policy based on this Act is available on request. If you are unsure or if you have information you do not wish to write down, please discuss this with Mr. Player.

FULL NAME

AND TITLE………………………………………………………………………..D.O.B…………………

Town/suburb of residence……………………………………………………………….………………..

Contact in case of emergency………………………………………………Phone………………………

Name of regular doctor (if applicable)……………………………………..Phone……………………….

Do you have an allergy to any drugs, foods, or medications (especially penicillin)? Yes No

Do you take any regular medications (including ‘puffers’ and oral contraceptives)? Yes No

Have you now or in the past had any of the following ailments?

Cardiovascular problems (heart complaint, murmur, angina, high blood pressure etc) Yes No

Respiratory problems (chest or breathing problems, for example asthma) Yes No

Stomach or bowel problems (gastric reflux etc) Yes No

Are you or might you be pregnant or breast-feeding? Yes No

Have you ever been in a high risk group for AIDS (ie. homosexual, bisexual,

user of intravenous drugs, sexual partner or child of any of the above)? Yes No

Have you ever been exposed to Creutzfeld-Jacob disease? Yes No

PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS YOU HAVE EVER HAD

Hepatitis Diabetes Epilepsy Rheumatic Fever Kidney Disease

Bleeding disorder Anaemia Tuberculosis Thyroid disease

Psychological condition Prosthetic appliance Stroke Any other condition

I have completed this form to the best of my knowledge and acknowledge that this represents an accurate medical history. On future visits I will advise of any changes to the history.

Signed………………………………………………………………………………..Date……………….

(Parent/Guardian if under 18 years)