STELLAR DENTAL

BASIC DETAILS

Title

First Name

Surname

Date Of Birth

Occupation

CONTACT DETAILS

Home Phone

Mobile Phone

Fax

Email

HOME ADDRESS

Unit Number / Level

Address

Suburb

Postcode

BUSINESS ADDRESS

Business Name

Address

Suburb

Postcode

POSTAL ADDRESS

Only fill out if different to your home address above.

Unit Number / Level

Street Address

Suburb

Postcode

P.0. BOX

EMERGENCY CONTACT

Who do we contact in case of emergency? Usually this is next of kin.

First Name

Surname

Relation To You

Unit Number / Level

Street Address

Suburb

Postcode

Phone

MEDICAL DOCTOR

Please provide details for your current GP.

First Name

Surname

Medical Practice

Address

Suburb

Postcode

Phone

Fax

DENTAL HISTORY

Do you have any of the following dental issues? Please answer yes or no for each.

Toothache
YesNo

Sensitive Teeth
YesNo

Bleeding Gums
YesNo

Loose Teeth
YesNo

Unsatisfactory Dentures
YesNo

Rapidly Decaying Teeth
YesNo

Lost Filling Cavity
YesNo

Grinding/Clenching of Teeth
YesNo

Worn/Broken Teeth
YesNo

Sounds/Clicking From Jaw
YesNo

Difficulty/Discomfort when Chewing
YesNo

Discoloured Teeth/Fillings
YesNo

Bad Breath
YesNo

COSMETICS

Is there anything you would like to change about your smile?

YesNo

GENERAL MEDICAL ISSUES

Do you have any of the following health issues? Please check each relevant box.

High Blood Pressure
YesNo

Diabetes
YesNo

Heart Ailment
YesNo

Thyroid Problems
YesNo

Rheumatic Fever
YesNo

Excessive Bleeding
YesNo

Asthma, Chest or Breathing Problems?
YesNo

Epilepsy
YesNo

Tuberculosis
YesNo

Hepatitis
YesNo

Stomach or Bowel Problems (e.g. Ulcer)
YesNo

AIDS/HIV
YesNo

SMOKING

Do You Smoke?
YesNo

How many cigarettes do you smoke per day?

Would You Like To Stop?
YesNo

ADDITIONAL QUERIES

Would you like to discuss these questions in private with the dentist?
YesNo

Do you have: an artificial hip, heart valve or other prosthetic implant?
YesNo

Have you ever had problems with dental treatment?
YesNo

Are you presently under medical care?
YesNo

Are you taking any drugs, medicine or tablets? If so, please list below.

Female patients, are you pregnant?
YesNo

Do you have any allergies?
YesNo

List any other previous illnesses you have.

List any medicines or products you are allergic to (i.e. Penicillin, Latex).

FORM AGREEMENT

I have completed this questionnaire to the best of my knowledge.

I understand that failure to make a full disclosure may place me at undue medical risk.

I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this.

I also give my permission for the practice to use the above contact details to send me appointment and checkup reminders.

I understand that no personal information will ever be shared with any other parties except where it concerns my dental treatment (i.e. research labs, other dental specialists, your GP, emergency contact etc).

Your personal information and medical records will be securely stored and never divulged to anyone except as required by other agencies involved in your dental treatment. Such agencies include (but are not limited to) confidential communications with medical specialists or dental laboratories..

I agree to the above.