Inline Form

Confidential Patient
Questionnaire and Medical History

Patient Details

Surname

Salutation

First Name

Gender

Date of Birth

Home Address

Suburb

Post Code

Occupation

Work Phone

Home Phone

Mobile Phone

Email ID

Emergency Contact Details

Name

Contact Number

Relationship

Doctor

Contact Number

Medical History

Are you currently receving any medical tretment?

Yes

Have you been a patient in hospital in the last two years?

Yes

Are you currently taking any medication?

Yes

Have you experienced any side effects from anaesthetics, pain killers or any drugs?

Yes

Have you had a general health check up in the last two years?

Yes

Have you had any prosthetic surgery?(ie. Hip replacement, heart valve)

Yes

Are you pregnant? If so how many Months

Yes

Are you allergic to rubber?

Yes

Do you have a blood clotting or bruising disorder?

Yes

Have you ever had any of the following?

Dental History

Approximate date of last Dental check up

6 Months

1 Year

Longer

Do you have any dental problem at present?

Yes

Do you become anxious or uncomfortable when receiving dental treatment?

Yes

How do you think you/the patient will react to treatment?

Well

Poor

Average

Corona virus(COVID 19) Patient Questionnaire With the current outbreak of the Corona virus(COVID 19), we are asking our patients to fill out the following form. Please understand, being in the health care industry, we must protact our patients and our staff. Due to the Corona virus(COVID 19), Dental treatment may be delayed. We thank you for your cooperation

Have you recently traveled to mainland China, Iran, Italy and South Korea?

Yes

Has anyone you have had contact with travelled to Mainland China, Iran, Italy and South Korea?

Yes

Have you travelled overseas recently(within 14 days.) If so what countries did you visit.

Yes

Have you had any contact with anyone that has been tested for Covid-19(that you know of)?

Yes

Have you had any contact with anyone that has been confirmed to have Covid-19?

Yes

Do you have any of the following Symptoms?

Fever

Yes

Flu like symptoms such as coughing and sneezing

Yes

Difficulty breathing

Yes

Sore throat

Yes

Fatigue

Yes