New and Current Patient Medical History Update Form

We would like to warmly welcome you to Smithfield Medical and Dental Centre. In an effort to

provide you with the highest possible care available, please fill out this form as completely as you

can. The information provided on this form is important to your dental and general health, we

understand that some of this information is of a personal nature and some of it may be regarded as

‘sensitive’. We value your privacy, so please be assured that the information you provide will be

treated with the utmost professional confidentiality. Even if you have been a valued long-standing

patient of the practice, it is important that we regularly update your Medical History information to

better aid us in providing you with a premium, professional health service. If you have any questions

or queries, please don’t hesitate to ask our friendly staff or discuss this with your dentist.

1. Your Details:

Full Name (title, first name, last name) :

___________________________________________________________________

Preferred Name: ________________ Date of Birth:_______________________

Postal Address ___________________________________________________ ___

__________________________________________ Postcode ___________

Mobile: _______________ Home: _________________ Work: ________________

E-mail Address:________________________ Occupation: ___________________

Medicare card number _______________________________Series ____________

Do you belong to a Private Health Insurance Fund? Yes ❑ No ❑

If yes, which one? ________________________________________

Private health insurance membership number __________________series ______

At Smithfield Medical and Dental we send appointment confirmations to our patients, if you

would like this service please indicate your preferred method of communication from the

practice, please circle:

E-mail SMS Call mobile Call home Call work

Who may we thank for referring you?

_______________________________________________________________________

If not a direct referral, how did you hear about our practice?

________________________________________________________________________

2. Additional Contact Details:

In case of emergency, who should be contacted?

Name: ______________________________________________________________

Relationship to patient: _________________________________________________

Contact Details: ________________________________________________________

3. Medical Health History:

Have you been under care of a medical doctor during the last 2 years? Yes ❑ No ❑

If yes, for what? __________________________________________________

Are you taking any prescribed or over the counter medication, natural remedies or

supplements? Yes ❑ No ❑If yes, please list name and dosage:

_____________________________________

Do you smoke? Yes ❑ No ❑ If Yes, how many per day? ________________________

Are you aware of having an allergic or adverse reaction to any medication or substance?

Yes ❑ No ❑_______________________________________________

Indicate which you have had previously or have at present

Y N Y N

Heart or Vascular Disease or

Surgery

Rheumatic Fever

Asthma or Bronchitis Fainting, Blackouts or

Dizziness

Chest Pain or Heart Attack Anxiety/Panic Attacks

Congenital Heart Problem Anemia

General Anesthetics/Operations Hepatitis A, B, C or carrier

Low Blood Pressure Liver Disease or Cirrhosis

Mitral Valve Prolapse / Artificial Prosthetic Joints

(hips/knee ect)

Epilepsy / Seizures Transplant

Reflux or Heartburn Stroke / TIA

Cancers or Tumours Blood Disease / Bleeding

Disorder

Lung or Respiratory Disorder Digestive Problems

High Blood Pressure HIV / AIDS

Sinus Trouble or Hay Fever Cancers or Tumours

Neurological Disorders Kidney Trouble

Thyroid Disorder Radiotherapy/

Chemotherapy

Valve Cardiac Pacemaker Pregnant

4. Dental Health History:

What is the main reason/s for your attendance today? Please circle

Pain Second Opinion Regular Checkup Missing teeth

Cosmetic Concerns (straightening, whitening)

When was your last dental appointment? __________________________________

what did you have done?

_____________________________________________________________

Have you had a bad dental experience? If so, please explain:

_______________________________________________________________________

___________________________________________________

How would you like to improve your teeth?

Get rid of pain Straight teeth Whiter teeth

Keep free of disease

Have you undergone any of the following?

Orthodontic treatment (Braces): Yes ❑ No ❑

Root Canal Therapy: Yes ❑ No ❑

Periodontal (Gum) Treatment: Yes ❑ No ❑

5. Practice Policies & Consent for Services:

1. I understand that all information provided will be held in the strictest of professional confidence.

2. I authorise the dental staff of Smithfield Medical and Dental Centre to perform all necessary dental

procedures that I require with my prior informed consent and accept full financial responsibility for said

treatment on the day of treatment.

3. I hereby Consent / Do Not Consent, the dentists to use any photos, radiographs and study models

they may take for the purpose of lecturing, publishing and education

Signature: Date:

________________________ ________________________