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Australian Denture Care Centre
Patient Information
Dental & Medical History Form
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Name:
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Last Name:
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Middle:
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D.O.B
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M
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F
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Occupation:
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Status:
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Address:
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Home Phone Number:
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Work Phone Number:
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Mobile Phone Number:
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Email Address:
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Language: 1st 2nd
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Next of Kin:
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Family GP:
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Address:
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Address:
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Home Phone Number:
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Phone Number:
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Work Phone Number:
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Mobile Phone Number:
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Mobile Phone Number:
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Email:
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Email Address:
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Last attended Date:
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Referred by:
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Patient Information
Medical History
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Please answer the following Questions:
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Y
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N
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Comments
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Date
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1. Are you currently under and medical treatment at the moment?
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2. In the last 5 years, have you undergone any major operations?
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2a. What major operation have you under gone?
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2b. When did the major operation take place? (Attachments – Comments) Yes No
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3. Have you had any type of heart valve or joint replacement surgery?
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4. Have you had any adverse response to drugs including penicillin?
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5. Are you allergic to any medications?
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5a. Please list the medications you are allergic to:
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6. Has a specialist/dentist/physician ever informed you that you have?
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6a. Heart Ailment or Heart Disease?
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6b. Heart Murmur?
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6c. High Blood pressure?
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6d. Respiratory Disease?
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6e. Diabetes?
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6f. Rheumatic Fever?
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6g. Rheumatism or Arthritis?
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6h. Tumours or Growths?
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6i. Blood Disease?
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6j. Liver Disease?
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6k. Kidney Disease?
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6l. Stomach or Intestinal Disease?
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6m. Venereal Disease?
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6n. AIDS?
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6o. Yellow Jaundice or Hepatitis? (Type of Hepatitis)
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7. Have you had any type of heart valve or joint replacement surgery?
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8. Do you have night sweats accompanied by weight loss or coughing?
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9. Are you currently part of a diet system or taking any dietary medication?
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10. Are you currently taking any medications or drugs at this present moment? (If yes, please list and include dose and mgs)
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11. Are you allergic to any know materials resulting in hives, asthma, eczema etc?
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12. Are you in general good health at the present moment?
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13. Do you have any wounds that have healed slowly or presented other complications?
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14. Are you pregnant?
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15. Do you have a history of fainting?
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16. Have you ever had any X-RAY treatments (other than diagnostic)?
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Patient Information
Dental History
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1. Do you have pain in or near your ears?
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2. Do you have any unhealed injuries or inflamed areas in or around your mouth?
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3. Have you experienced any growth or sore spots in mouth?
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4. Does any part of your mouth hurt when clenched?
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5. Have you ever had local dental anaesthetic?
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5a. Do you have any reactions or allergic symptoms to dental anaesthetic?
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6. Have you had Prolonged Bleeding after extractions in the past?
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7. Have you ever been diagnosed with Periodontal (Gum) disease?
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8. Do your gums bleed?
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9. Have you been instructed to properly care for your teeth and gums?
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10. Do you chew on only one side of your mouth?
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10a. What are your reasons for chewing on the one side of your mouth?
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11. Do you currently have dental complaints?
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12. Do you habitually clench or grind your teeth during the night or day?
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13. Have you had a full mouth X-RAY taken or OPG, etc?
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14. Currently, is your mouth and or teeth sore to pressures or irritants? (Cold, hot, sweets)
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14a. Where are these pressures or irritants located?
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