Redcliffe Dental
Please Select : MrMrsMsMissMasterDr
Surname*:
First Name*:
Address:
Suburb:
Postcode:
Phone Home:
Work:
Mobile:
Date Of Birth:
Occupation:
Parent/Guardian names if under the age of 16:
Are you in a Private Health Fund for Dental? YesNo
If yes, which one?
Are you covered by Veterans Affairs? YesNo
If yes, card number?
How did you find out about Our Practice? AdvertisingFamily & friendsInternetWalk-in/Seen the signYellow PagesOther
Have you ever had or do you have any of the following? (Please tick)
High Blood Pressure
YesNo
Diabetes
Heart Conditions or Heart Surgery
Arthritis
Excessive Bleeding
Asthma or Bronchitis (Which one?)
Rheumatic Fever
HIV or Hepatitis A,B or C (Which one?)
Hip/Knee Replacement (Which one?)
Epilepsy
Anxiety or Depression (Which one?)
Hay Fever or Sinus
Allergies
Ladies, are you pregnant?
Radiation therapy to the head or neck
Treatment therapy for cancer
Do you get headaches?
Do you breathe through your mouth?
Do you clench or grind your teeth?
Do you snore?
Do you feel refreshed in the morning when you wake up?
Diseases of bone/other cancer that has spread to the bone (eg: osteoporosis, pagets disease) Include any medications taken for this:
Other serious injury or illness:
List any medication you are currently taking:
GP's Name and location:
Signature:
Date:
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