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Clinic Hours
Day
Hours
M
8:00 am - 6:00 pm
T
8:00 am - 6:00 pm
W
8:00 am - 6:00 pm
T
8:00 am - 6:00 pm
F
8:00 am - 6:00 pm
S
8:00 am - 1:30 pm
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Diamond Smiles Dental
(08) 9405 2225
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Contact Us
New Patient – Medical History Form
Please Note:
So we can ensure that we are looking after your needs and providing you with the best possible care please review and complete the following questionnaire.
*Fields are required.
Salutation:
*
Mr.
Ms.
Mrs.
Dr.
Prof.
First Name:
*
Surname:
*
DOB (dd/mm/yyyy):
*
Email:
*
Home:
Mobile:
*
Work:
Address
Country:
*
State/Province:
*
City:
*
Street:
*
Postal Code:
*
Occupation:
*
Person responsible for account:
*
Do you have private health insurance?:
Insurance Company:
–None–
BUPA
CBHS
DentaCare
Government Subsidy (WA)
HBF
HCF
Medibank Private
NIB
Smile
Standard
Veterans Affairs
Member Number:
Reference No. on Card:
GP Name:
*
Practice Name:
*
Phone:
*
Emergency Contact Name:
*
Relationship to yourself:
*
Phone:
*
Is another member of your family a patient here?:
if Yes
Name:
Relationship:
How did you hear about us?:
*
–None–
Web search
Magazine
Newspapaer
Television
Word of mouth
The state of your health may have a very significant impact on your dental care. Some medicines may interfere with your dental treatment or react with the materials / medications used by your dentist.
Medical Conditions:
Rheumatic Fever
Heart Complaint / Surgery
Heart Valve Replacement
Cardiac Pacemaker
High/Low blood pressure
Diabetes
Kidney Disease
HIV
Blood Disorders
Nervous System Disorders
Hepatitis, jaundice or liver disease
Depression/ Anxiety
Transplant Therapy
Cancer
Radiation Therapy
Chemotherapy
Epilepsy/seizures
Osteoporosis or any bone disorders
Asthma/ Bronchitis/Lung Conditions
Excessive Bleeding/bruising
Arthritis, joint problems
Thyroid Disease
Inflammatory bowel disease
Joint Replacement
Other
Other details:
<br />
Medication: Please include all prescription, herbal or over the counter medications that you are currently taking and the dosage:
Have you ever had Botox or Dermal filler:
Do you have any disabilities or special needs? :
if yes, please specify:
Are you allergic or sensitive to any foods, chemical or substances (eg. Milk proteins/latex/elastoplast/essential oils/ aromatherapy)?:
if yes, please specify:
Do you currently or have you ever smoked?:
When did you quit?: (dd/mm/yyyy)
Have you ever used illicit substances?:
if yes, please specify:
Do you drink alcohol?:
if yes, how many standard drinks per day?:
Females Only:
Could you be or are you currently pregnant?:
– if yes Due date (dd/mm/yyyy):
Are you currently breastfeeding?:
Do you suffer from the following?
Bleeding gums/bad breath
Discoloured teeth
Difficulty chewing/functioning
Grinding your teeth
Biting lips and cheeks
Sensitivity to hot or cold
Jaw pain or clicking
Snoring (loud enough to hear through closed door)
Has anyone noticed you stop breathing during sleep?
Do you often feel tired, fatigued during the day?
Are you happy with your smile/dental condition?
Please give details:
What is the purpose of your visit today?:
*
How long since your last visit to a dentist? (dd/mm/yyyy):
*
Are you anxious about your dental visit? :
