Microsoft word - health questionnaire

PERSONAL DETAILS (Confidential)

Surname:___________________ First Name:______________________ Title:_______
Address:_____________________________________ Suburb: ______________ Postcode: _____
Home Phone: ________________ Mobile Phone:___________________________________
Business Phone:______________ Email:__________________________________________
Date of Birth: / /
Occupation:
____________________________________
How did you find out about us: □ Yellow pages □Internet □Word of mouth
□Saw sign/ Building □ Referral from specialist/Dentist________________ □Other__________
Preferred method of contact:
□ Phone
□ Reminder card
Are you happy with the appearance of your teeth?

MEDICAL HISTORY
Doctor’s Name: __________________________
 Are you currently being treated for any health
 Have you been admitted to hospital in the last two
 Do you have or have you had any heart problems?
□ Heart Murmur
Pacemaker
□ Arrhythmias
□ Valve Replacement/Failure
□ Other: _____________

 Have you, or any member of your family, ever had excessive bleeding or bruising: Yes □ No □
 Do you smoke? Yes
 Please tick if you have or have previously had any of the following:
□ Asthma
□ Hepatitis
□ High Blood Pressure
□ Lung Disease
□ Liver Problems
□ Stroke
□ Hip / Joint Replacement
□ Arthritis
□ Epilepsy
□ HIV / AIDS
□ Stomach or Bowel Problems
□ Diabetes
□ Depressive Illness
□ Kidney Problems □ Rheumatic Fever
□ Cancer
 Are you taking any tablets, medicines, inhalers or injections of any kind? Yes □ No □
If yes, please list: _______________________________________________________________
______________________________________________________________________________
 Have you previously had an allergic reaction e.g. to pills, medicines (e.g. penicillin), latex or local
If yes, please list: _______________________________________________________________
______________________________________________________________________________
 Females: Are you pregnant?

 Appointments not attended or cancelled without 24 hours notice will be charged for.
 Payment is required on the day of treatment. If an account is taken away, an administration of 10% will be added.
 Any unpaid debt will be forwarded to a collection company, expenses incurred in this process will be charged to the patient.
 St Albans Dental Centre reserves the right to discontinue treatment on a patient at our discretion, for any reason.
 St Albans Dental Centre reserves the right to take a sample of blood for analysis in the case of a needle stick injury to a staff
I have read the above questionnaire and completed it to the best of my knowledge SIGNED:_____________________________________ DATE: _______________ Relationship to patient (if applicable) _____________________________________ S:\Marketing\Practice Marketing Material\@NZ\St Albans Dental Centre - Platts\Website\Health Questionnaire.doc

Source: http://www.stalbansdentalcentre.co.nz/file_storage/St%20Albans%20Dentist%20-%20New%20Patient%20Formv2.pdf