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
Australian Society of Acupuncture Physiotherapists Inc GUIDELINES FOR SAFE ACUPUNCTURE AND DRY NEEDLING PRACTICE JULY 2007 CONTENTS 1) Forward 2) Introduction 3) Management of Needle Accidents & Adverse Reactions Waste Disposal Advise for Needles or Bodily Fluids ASAP Guidelines for Safe Acupuncture and Dry Needling Practice This document is designe
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