Medical History Form

Title

Given Name

Surname

Address

Postcode

Phone (Home)

Phone (Work)

Phone (Mobile)

Date of Birth

Who referred you to this practice?

Private Health Insurance Company

Occupation

Medical History

Have you had any of the following? Please tick.

Are you under medical care at the present time? If yes, please specify.

Have you ever had a serious illness? If yes, please specify.

Are you taking any drugs, medicines, pills or tablets? If yes, please specify.

Do you carry any infectious disease?

Do you have private and confidential matters which you wish to discuss with Dr Lazar?

Do you smoke?

If yes, what do you smoke (cigarettes, cigars, pipe, other)?

If yes, for how long?

How many per day do you smoke?

What is the main reason for your visit today?

How long since your last dental visit?

Are you experiencing any discomfort in your teeth, gums, jaws or face?

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

Do your gums ever bleed when you clean your teeth?

Have you ever experienced any difficulty with any previous dental extractions?

Have you ever experienced any injury to the face or jaw?

Do you experience any problems chewing food?

Do you ever experience any clicking or tenderness in or around the jaw joint and/or ear?

Are you aware of grinding or clenching your teeth?

Have you had any previous orthodontic treatment, periodontal treatment or oral surgery?

Are you unsatisfied with the appearance of your teeth?

How often do you clean your teeth?

Do you use dental floss to clean between your teeth?

Are you apprehensive about receiving dental treatment?

In submitting this form I acknowledge that this represents an accurate medical history.*

I understand that all medical details will be treated with complete professional confidentiality.*