Adult Medical history form

Patient’s name*

Email*

Patient DOB*

Phone*

Postcode*

Address*

Gender*

Pregnancy*

Payee’s name (person responsible for payment of account)*

Payee’s number*

Address*

Do you have a Private Health Fund?*

Dentist’s name*

Does the patient have a health problem? *

Is there a history of serious illness, accident or operation? *

Is the patient under a doctor’s care for any problem at this time? *

Is the patient taking any medication? *

Does the patient have any allergies or drug sensitivities? *

Has the patient had an orthodontic consultation previously? *

Has the patient had any previous orthodontic treatment? *

Has the patient had any injury to the teeth? (this includes both baby & permanent teeth) *

Has the patient had any injury to the face, jaw or gums? *

Has the patient had any cysts or tumours of the jaws or gums? *

Have you been informed of any missing or extra permanent teeth?*

Does the patient suck fingers or thumb, or have a similar habit*

Date of last dental examination

Reason for seeking orthodontic treatment *

Do you have or ever had any of the following?*

How did you find out about us? *

Date