Patient details

First Name *

Last Name *

Date of birth *

Street address *

Suburb *

Postcode *

Mailing address

Home phone

Mobile phone

Work phone

Email *

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Employer

Position

Medical Physician

Dental Coverage

Dental and Medical history

Time since last visit

What was done?

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Are you experiencing any discomfort now?

YesNo

What is the discomfort?

Have you noticed any changes in your mouth?

YesNo

What changes?

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Do you regularly see a dental hygienist?

Is there anything about dental hygiene that you would like us to address?

Lost any teeth?

YesNo

Replacement by a

Fixed bridgeDenturesImplants

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Have you ever had orthodontic treatment?

YesNo

When?

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Do you grind or clench your teeth?

YesNo

Do you have frequent headaches?

YesNo

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Do you snore?

YesNo

Are you a mouth breather?

YesNo

Do you use a CPAP machine?

YesNo

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How do you feel about your smile?

Have you had botox or fillers?

YesNo

Have you had botox for headaches?

YesNo

Are you happy with the texture of your skin?

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

AsthmaDiabetes (Type 1 or 2)Heart Surgery/problemsRheumatic feverLow/High blod pressureFainting/seizuresSmokerRadiation/chemotherapyKidney and/or liver diseaseSexually transmitted diseaseThyroid problemsUnder/overactive thyroidRespiratory problemsPsychiatric treatmentHepatitis A, B or CImmune deficienciesStomach problems/refluxHerpesAllergies/Hay Fever

Are you pregnant?

YesNo

Medications

Surgeries

Allergies

Other concerns

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