Medical Dental History Form It is important to know details about your medical history as these could affect the success of oral health care (dental treatment). The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the reverse of this form. Name* First Last Title*Date of Birth* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Phone (Home)*(Work)(Mobile)Do you have private health insurance for dentistry?* Yes No Which Health FundDo you have confidential medical information that you do not wish to write down and would prefer to speak to the dentist about?* Yes No Approximately how long since a dentist last checked your teeth?*Do you have, or have you ever had, any of the following medical conditions?(Please tick the appropriate box(es)Steroid Therapy* Yes No Rheumatic Fever* Yes No Epilepsy* Yes No Asthma* Yes No Diabetes* Yes No Heart Valve Disorder* Yes No Stroke* Yes No Radiation Therapy* Yes No Kidney Disease* Yes No Excessive Bleeding* Yes No Heart Complaint* Yes No Nervous Condition* Yes No Tuberculosis* Yes No Thyroid Disease* Yes No Heart Murmur* Yes No High or Low Blood Pressure* Yes No Prosthetic Implant e.g Artificial Hip* Yes No Cardiac Pacemaker* Yes No Stomach or Digestive Condition* Yes No Hepatitis or other Liver Diseases* Yes No Contact with HIV/AIDS Virus* Yes No Bronchitis, Emphysema, or other Lung Diseases* Yes No Anaemia, Leukaemia or other Blood Diseases* Yes No Transplanted Organ or Marrow* Yes No Have you ever had any teeth extracted? If so:Did the Dentist have any difficulty extracting the teeth?* Yes No DetailsDid you experience any problems following the extraction?* Yes No DetailsAre you being treated by a doctor at present?* Yes No DetailsAre you being treated by a doctor at present?* Yes No DetailsAre you taking any tablets or medicines (prescribed or ove-the-counter) at present?* Yes No DetailsDo you normally require antibiotic cover before dental treatment?* Yes No DetailsDo you smoke?* Yes No DetailsAre you pregnant? (Females)* Yes No DetailsWho is your medical practitioner?*Phone Number*Please list any drugs or medicines you are allergic too?*Please list any other known allergies (including latex):*I have read and accept the Privacy Policy.*I accept the Privacy PolicyPlease click here to Read the Privacy Policy.Signature*Please sign the form box above and submit with form application.CAPTCHA
