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Patient Information
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denotes fields that must be completed
Title
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Mr
Mrs
Miss
Ms
Dr
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Surname
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Preferred Name
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Given Name
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Date of Birth
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Address
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Postcode
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Phone (Private)
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Phone (Work)
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E-mail
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Name and Address of Parent/Guardian if under 20
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Name of GP
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Name of last Dentist
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How long since your last visit to a Dentist?
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Why did you leave your last Dentist?
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Do you have any current dental problems?
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Do you wish to become a regular patient?
Yes
No
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Dental Questionnaire
Are your teeth sensitive to: Heat, Cold, Sweets, Biting Pressure?
Yes
No
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Do your gums bleed when brushing?
Yes
No
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Have you noticed any gum swelling around any teeth?
Yes
No
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Does food catch badly between your teeth?
Yes
No
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Do you have an unpleasant taste or odour in the mouth?
Yes
No
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Do you avoid any part of your mouth while chewing or brushing?
Yes
No
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Are you dissatisfied with the appearance of your teeth?
Yes
No
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Are you dissatisfied with the function of your teeth?
Yes
No
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Do you get frustrated because you always have something to be treated or repaired when you visit the dentist?
Yes
No
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Do you smoke?
Yes
No
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Have you ever had any teeth removed?
Yes
No
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If so, how long have these teeth been missing?:
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Do you snore or have problems with breathing (sleep aponea) when asleep?
Yes
No
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Do you have any particular dental fears?:
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Confidential Health Questionnaire
In order to provide the best and safest dental treatment your dentist needs to know of any medical problems which may affect your treatment:
Are you receiving any medical treatment at the present time?
Yes
No
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Have you ever had any of the following?
Rheumatic Fever
Yes
No
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Heart Trouble
Yes
No
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High Blood Pressure
Yes
No
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Epilepsy
Yes
No
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Diabetes
Yes
No
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Any other illness:
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Have you ever had contact with the AIDS virus or Hepatitis B virus?
Yes
No
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Are you taking any tablets, capsules, medicines or drugs?
Yes
No
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If Yes, please list
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Have you any allergies to medicines that you are aware of?
Yes
No
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If Yes, please list
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Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
Yes
No
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Do you have an artificial/prosthetic joint?
Yes
No
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Have you ever had a reaction to a local anaesthetic?
Yes
No
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(Women) Are you pregnant?
Yes
No
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If so, when are you due?
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Reminder System
We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
SMS
Mobile
Home Phone
Work Phone
E-Mail
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How did you hear about us?
Referral Source
Search Engine
DENTAL CARE NETWORK TM
Corporate Dental Program
Practice Website
Signage
New Patient Offer Card
Advertising
Referred by Family or Friend
Patient Referral
Live in the Area
Radio
Newspaper
Facebook
Health Professional
Veterans Affairs
Other
Walk By
Yellow Pages
Yellow Pages online
Care to Share
Google
Bupa
HCF
Other Health Funds
Bridal Site
Mail Drop
3000 Melbourne Magazine
Corporate Partnership
GP Referral
Other Source
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Keep Informed
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Yes
No
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Consent for Services
Ticking this check box certifies that:
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I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed upon by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.
Captcha
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Refresh
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