Home » Try Medical Questionnaire

Welcome Trialling Dentist

Dear Doctor,

Welcome to the trial of the Dental Patient Triage (DPT) medical questionnaire – your solution for effortless patient onboarding.

We invite you to act as a patient and complete the questionnaire below, using an email address you can access on your phone. This will allow you to see firsthand how easily you can review the submitted medical history via email, ensuring accurate and safe care plans with minimal effort. This intuitive tool is designed to save you time, enhance patient safety, and integrate smoothly into your practice’s workflow. Test it now and experience the difference!

Best regards,
Dr. Denver Maloney, BDS (Syd)
Dental Patient Triage

Practice Name Medical Questionnaire

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- Step 1 of 4

WELCOME!

We’re so grateful you’ve chosen us to support your dental care journey. Here are a few notes to make this form as smooth as possible:

Questions are placed below the answer fields for clarity, guiding you gently through the process.
Your privacy is our priority. We use unique details to protect your information, ensuring only our caring team can access it.

Your responses help us provide personalised care, and we’re here to make you feel at ease.

DATE COMPLETED:

PATIENT STATUS: *

- First time patient
- Already a valued patient

APPOINTMENT BOOKED: *

- Online
- Over the phone
- At the practice

We’d love to know how you booked your appointment so we can make the process as comfortable and convenient as possible for you.

MEDICAL HISTORY COMPLETED: *

- Not previously completed
- Yes, more than 12 months ago, and there have been no changes in my health
- Yes, more than 12 months ago, and there have been some changes in my health
- Yes, less than 12 months ago, and there have been some changes in my health

Have you filled out our medical history questionnaire before? Please let us know so we can prepare for your visit with care.

HEADSHOT PHOTO:

Drag & Drop Files, Choose Files to Upload

We’re excited to get to know you! Please share a selfie or photo to help our team warmly welcome you. Your comfort is our priority.

UNIQUE PATIENT IDENTIFIER#: *

- Yes
- No

Did you receive a Unique Patient Identifier in the SMS or email with this form’s link? Please let us know, and we’ll guide you through the next steps with ease.

UPI#: *

If you have a Unique Patient Identifier (UPI), please share it here. This helps us connect your responses to your patient file, ensuring a seamless and caring experience for your visit.

PATIENT FIRST NAME: *

Your privacy means the world to us. Please share only the patient’s first name to help us personalise your care while keeping your information safe.

YEAR OF BIRTH: *

Please enter the patient's year of birth. This helps us tailor our care to their unique needs, and is also used to encrypt your completed form as a secure PDF before it is emailed to both you and the practice. Your year of birth will be the PIN to unlock and view the information — ensuring only you and the practice can access it.

MY CONTACT DETAILS: *

- Have not changed
- May have changed

Have your phone number or email changed since you last completed this form? Please let us know so we can stay connected and support you seamlessly.

PATIENT PHONE NUMBER: *

Please share the phone number you used to book the appointment for yourself or your loved one. This helps us identify you and ensure a warm, smooth visit.

PATIENT EMAIL: *

Please share an email address where we can send important updates about the patient’s dental care. We may also use it to connect with specialists to ensure the best support for you.

BODY MASS: *

- Metric (cm and kg)
- Imperial (ins and lbs)

Please choose the units (metric or imperial) you’re most comfortable using for your height and weight. We’re here to make this easy for you.

WEIGHT (pouds):

Please share the patient’s approximate weight in pounds to help us provide care tailored to their needs.

HEIGHT (inches):

Please share the patient’s approximate height in inches so we can better understand their needs and provide thoughtful care.

WEIGHT (kilograms):

Please share the patient’s approximate weight in kilograms to help us offer care that’s just right for them.

HEIGHT (centimetres):

Please share the patient’s approximate height in centimetres to support us in providing personalised, compassionate care.

I IDENTFY AS: *

We want to honor your identity. Please share how you identify, and we’ll ensure your care reflects your unique self with respect and warmth.

GENDER: *

- Female (genetic)
- Male (genetic)
- Other

Please choose the option that feels most true to you. We’re here to support you with care and respect.

PATIENT IDENTIFIES AS: *

Please share how the patient identifies so we can provide care that honors their unique identity with kindness and understanding.

GENDER THERAPY: *

- Yes
- No

Has the patient used hormones or other medications for gender therapy? Please share so we can provide safe, supportive care tailored to their needs.

Your Gender-Affirming Care

We’re here to support your journey. Sharing any gender-affirming medications helps us provide safe, personalised dental care that respects your needs and ensures your comfort.

GENDER MEDICATION: *

Please share the name of any gender-affirming medication you’re taking. This helps us ensure your dental care is safe and supportive.

PREGNANCY: *

- I may be pregnant
- I am pregnant
- I am not pregnant
- I am in an IVF programme

WEEKS PREGNANT: *

If you’re pregnant, please share how many weeks along you are. We’re here to provide gentle, caring support for you and your baby.

COMPLETED BY: *

- Patient
- Partner
- Parent
- Guardian
- Foster Carer
- Carer
- Dental staff

Please let us know who is filling out this form so we can better understand your perspective and provide the most thoughtful care.

Thank You for Helping!

We’re so grateful for your time in completing this form. Please share your contact details so we can connect with you and provide the best care possible.

STAFF NAME: *

PARTNER NAME: *

First

Last

PARTNER PHONE NUMBER: *

For your peace of mind, please share a phone number where we can reach you in case of emergencies involving the patient. We’re here to keep you safe.

PARTNER EMAIL: *

Please provide an email address where we can send important updates about the patient’s dental care. We may also use it to coordinate with specialists to ensure the best support.

PARENT NAME: *

First

Last

PARENT PHONE NUMBER: *

To ensure safety, please share a phone number where we can contact you in case of emergencies involving the patient. We’re here for you.

PARENT EMAIL: *

Please share an email address for important updates about the patient’s dental care. We may also use it to connect with specialists to provide the best care possible.

GUARDIAN NAME: *

First

Last

GUARDIAN PHONE NUMBER: *

For your loved one’s safety, please provide a phone number where we can reach you in case of emergencies. We’re here to support you.

GUARDIAN EMAIL: *

Please share an email address where we can send key updates about the patient’s dental care. We may also use it to collaborate with specialists for the best care.

FOSTER CARER NAME: *

First

Last

FOSTER CARER PHONE NUMBER: *

To keep the patient safe, please share a phone number where we can contact you in emergencies. We’re here to care for you both.

FOSTER CARER EMAIL: *

Please provide an email address for important updates about the patient’s dental care. We may also use it to coordinate with specialists to ensure excellent care.

CARER NAME: *

First

Last

CARER PHONE NUMBER: *

For the patient’s safety, please share a phone number where we can reach you in case of emergencies. We’re here to support you.

CARER EMAIL: *

Please share an email address where we can send vital updates about the patient’s dental care. We may also use it to connect with specialists for the best support.

Your Health Journey

We’re honored to learn more about your health to provide care that’s tailored to you. Your responses help us support you with kindness and understanding.

HEART CONDITION: *

- No
- Yes

Have you ever been diagnosed with a heart condition? Please share so we can provide safe, compassionate care tailored to your needs.

Your Heart Health

We’re here to care for your whole self. Sharing any heart conditions helps us ensure your dental treatments are safe and effective, supporting your health with warmth and expertise.

HEART CONDITION TYPE: *

- Heart Valve Replacement
- Heart Attack
- Pacemaker
- Heart Murmur
- Open Heart Surgey
- By-Pass Surgery
- Arrhythmia
- Other Heart Condition

Please select any heart conditions you’ve been diagnosed with. Your openness helps us provide gentle, personalised care to keep you safe.

HEART VALVE REPLACED: *

Please share the year of your heart valve surgery. This helps us understand your health history and provide thoughtful care.

PACEMAKER PLACED: *

Please tell us the year your pacemaker was placed. This allows us to tailor your care with precision and compassion.

OPEN HEART SURGERY: *

Please share the year of your open heart surgery. We’re here to support your health with care and understanding.

BYPASS SURGERY: *

Please tell us the year of your by-pass surgery. This helps us provide safe, personalised care for you.

OTHER HEART CONDITION: *

Please share any details about your heart condition, even if you’re unsure of the name. We’re here to listen and support you with kindness.

HEART MEDICATION: *

- Yes
- No

Are you taking any medications for your heart condition? Please let us know so we can ensure your dental care is safe and supportive.

HEART CONDITION MEDICATIONS: *

Please share the name, dose, and frequency of your heart medication, or let us know if you’re unsure. We’re here to help make this easy for you.

PROPHYLACTIC ANTIBIOTICS: *

- No
- Yes
- I am not sure

Has your heart doctor recommended antibiotics before dental treatments? Please share so we can keep your care safe and comfortable.

Important Health Information Needed

To ensure your safety, please check with your heart doctor or GP about whether antibiotics are needed before dental procedures that may cause gum bleeding. Once you know, kindly share with our team so we can care for you with confidence.

BLOOD PRESSURE: *

- No
- Yes

Have you ever been diagnosed with a blood pressure condition, like high or low blood pressure? Please let us know so we can provide care that supports your health.

Your Blood Pressure Health

We’re committed to your well-being. Sharing any blood pressure conditions helps us tailor your dental care to keep you safe and comfortable, as your blood pressure can affect treatment outcomes.

BLOOD PRESSURE CONDITION: *

- High blood pressure
- Low blood pressure

BLOOD PRESSURE MEDICATION: *

- Yes
- No

Are you using any medications to manage your blood pressure? Please share so we can ensure your dental care is safe and effective.

BLOOD PRESSURE MEDICATION DETAILS: *

LIVER CONDITIONS: *

- Yes
- No

Have you been diagnosed with any liver conditions, like Hepatitis or Cirrhosis? Please let us know so we can provide gentle, informed care.

Your Liver Health

We care about your overall health. Sharing any liver conditions helps us ensure your dental treatments are safe and supportive, as liver health can influence your oral care.

LIVER DISEASE: *

- Hepatitis A
- Fatty liver disease
- Liver Cirrhosis
- Other Liver Condition

Please select any liver conditions you’ve had. Your openness helps us provide care that’s safe and tailored to you.

OTHER LIVER CONDITION: *

Please share details about your liver condition, even if you’re unsure of the specifics. We’re here to support you with understanding and care.

KIDNEY CONDITION: *

- No
- Yes

Have you been diagnosed with any kidney conditions, such as Polycystic Kidney Disease or kidney stones? Please share so we can provide safe, compassionate care.

Your Kidney Health

We’re here to support your health journey. Sharing any kidney conditions helps us ensure your dental care is safe and effective, as kidney health can impact your treatment.

TYPE OF KIDNEY CONDITION: *

- Chronic Kidney Disease (CKD)
- Kidney Failure
- Diabetic Kidney Disease
- IgA Nephropathy
- Polycystic Kidney Disease (PKD)
- Simple Kidney Cysts
- Kidney Infection (Pyelonephritis)
- Kidney Stones
- Kidney Transplant Recipient
- Other Kidney Condition

Please select any kidney conditions you have. This helps us provide gentle, personalised care to keep you safe.

ANTI-REJECTION MEDICATION: *

- Yes
- Yes, but I am unsure of the name of the medication
- No

Are you taking anti-rejection medications after a kidney transplant? Please let us know so we can tailor your care with safety and compassion.

ANTI-REJECTION MEDICATION: *

Please share the name, dose, and frequency of your anti-rejection medication, or let us know if you’re unsure. We’re here to make this process supportive.

OTHER KIDNEY CONDITION: *

Please describe any other kidney conditions you have, even if you’re unsure of the details. We’re here to listen and care for you.

BONE CONDITION: *

- Yes
- No

Have you been diagnosed with any bone conditions, like osteoporosis or osteoarthritis? Please share so we can provide care that supports your health.

Your Bone Health

We care about your overall well-being. Sharing any bone conditions helps us ensure your dental treatments are safe and effective, supporting your health with kindness.

BONE CONDITION TYPE: *

- Osteoporosis
- Paget's Disease
- Osteopenia
- Osteogenesis imperfecta
- Osteoarthritis
- Osteomyelitis
- Bone cancer and tumours
- Osteomalacia
- Joint Replacement
- Other Bone Condition

Please select any bone conditions you’ve been diagnosed with. Your openness helps us provide safe, compassionate care tailored to you.

OSTEOPOROSIS MEDICATION: *

- Yes, taking medications
- Yes, but I am unsure of the name of the medication
- I have stopped taking medications
- Never taken any medications

Are you using any medications or supplements to manage osteoporosis? Please share so we can ensure your dental care is safe and supportive.

JOINT REPLACEMENT DATE:

Please share the year and month of your last joint replacement, or let us know if you’re unsure. We’re here to support you with care.

OSTEOPOROSIS MEDICATION:

Please share the name, dosage, frequency, and last dose date of your osteoporosis medication, or let us know if you’re unsure. We’re here to help.

OTHER BONE CONDITION: *

Please describe any other bone conditions you have, even if you’re unsure of the specifics. We’re here to listen and provide caring support.

PROPHYLACTIC ANTIBIOTICS: *

- No, not needed
- Yes, needed
- Unsure

Has a doctor advised you to take antibiotics before dental treatments like extractions or cleanings? Please share so we can keep your care safe.

GASTROINTESTINAL, STOMACH, & DIGESTIVE: *

- No
- Yes

Have you been diagnosed with any digestive conditions, like reflux or Crohn’s disease? Please let us know so we can provide gentle, informed care.

Your Digestive Health

We’re here to support your whole health. Sharing any digestive conditions helps us address any related oral symptoms, like ulcers or inflammation, with care and expertise.

GASTROINTESTINAL CONDITION: *

- Reflux
- Oesophageal Condition
- Stomach Ulcer
- Cancer
- Chron's Disease
- Celiac disease
- Diverticulitis
- Gastric Banding
- Gastric Sleeve Surgery
- GORD (Gastro-Oesophageal Reflux Disease)
- Malabsorption
- Peptic Ulcer
- Polyps
- Short Bowel Syndrome
- Ulcerative Colitis
- Other Gastric Surgery
- Other Gastrointestinal Condition

Please select any digestive conditions you have. Your responses help us provide safe, compassionate care tailored to your needs.

OTHER GASTRIC SURGERY: *

Provide details about the other gastric surgery you have undergone.

OTHER GASTROINTESTINAL CONDITION: *

Provide details about the other gastrointestinal conditions you have been diagnosed with.

GASTROINTESTINAL MEDICATION: *

- No
- Yes

Are you taking any medications for one or more gastrointestinal conditions?

MEDICATION TYPE: *

Provide the name, dose, and frequency of the medication(s) you are taking to treat one or more gastrointestinal conditions.

LUNG DISEASE: *

- No
- Yes

Do you have a lung condition such as Asbestosis, Asthma, Bronchiectasis, Bronchitis, Bronchiolitis, Chest Infection, Chronic Obstructive Pulmonary Disease (COPD), Cystic Fibrosis, or Pulmonary Oedema?

Lung Disease

Patients with lung conditions such as asthma, chronic obstructive pulmonary disease (COPD), or other respiratory issues may have difficulty breathing during specific dental procedures. Additionally, some medications used in dentistry can affect the respiratory system.

Understanding a patient's lung condition allows the dentist to tailor treatment plans and take necessary precautions to ensure their safety and well-being during their dental visit. It also helps determine the most suitable anaesthesia and sedation options and identify potential complications that may arise due to compromised lung function.

Ultimately, being aware of a patient's lung condition enables the dentist to provide appropriate care that minimises risks and maximises comfort for the individual undergoing dental treatment.

LUNG CONDITION: *

- Asbestosis
- Asthma
- Bronchiectasis
- Bronchitis
- Bronchiolitis
- Chest Infection
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic Fibrosis
- Pulmonary Oedema

What lung conditions do you have? Select all that apply.

LUNG CONDITION TREATMENT: *

- No
- Yes

Do you require any form of treatment for your lung condition?

LUNG CONDITION TREATMENT: *

- I take some medication
- I require breathing support such as Oxygen
- I require no treatment

What treatment do you require for your lung condition?

LUNG CONDITION MEDICATION: *

Provide the name, dose and frequency of your medication for the lung condition.

BREATHING SUPPORT: *

Please describe the breathing support you need for your lung condition.

MENTAL HEALTH: *

- No
- Yes

Do you have a mental health condition such as Anxiety Disorder, Depression, Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Schizophrenia, Eating Disorders, Disruptive behaviour and dissocial disorders, or Neurodevelopmental disorders?

Mental Health

Your dentist must know about any mental health conditions you have because mental health can significantly impact your oral health and dental treatment.

MENTAL HEALTH CONDITION: *

- Anxiety
- Depression
- ADHD
- Bipolar Disorder
- Schizophrenia
- Autism
- Eating Disorder
- Obsessive Compulsive Disorder.
- Paranoia
- Other

What mental health conditions have you been diagnosed with? Select all that apply.

OTHER MENTAL HEALTH CONDITION: *

What other mental health conditions do you have?

MENTAL HEALTH MEDICATION: *

- No
- Yes

Are you taking any medications for your mental health condition?

ANXIETY MEDICATION: *

Please write the name, dose, and frequency of the medication you are taking for anxiety.

DEPRESSION MEDICATION: *

Please write the name, dose, and frequency of the medication you are taking for depression.

SCHIZOPHRENIA MEDICATION: *

Please write the name, dose, and frequency of the medication you are taking for schizophrenia.

ADHD MEDICATION: *

Please write the name, dose, and frequency of the medication you are taking for ADHD.

AUTISM MEDICATION: *

Please write the name, dose, and frequency of the medication you are taking for autism.

OTHER MENTAL HEALTH MEDICATION: *

Please write the name, dose, and frequency of medication you are taking for your other mental health condition(s).

Headaches

Headaches can often be linked to various dental issues, such as jaw joint disorders, teeth grinding, and bite alignment. We can identify potential underlying causes from the oral cavity by asking patients about their headache history and symptoms.

HEADACHES: *

- Yes
- No

Do you experience frequent headaches?

HEADACHE EXPERIENCE: *

- Started recently
- Commenced some time ago
- My headaches started after an event that happened to me
- - I have had frequent headaches for as long as I can remember

Do you experience frequent headaches?

HEADACHE TRIGGERING EVENT: *

Describe the event(s) that triggered your headache(s).

HEADACHES COMMENCED: *

How long ago did your first headache start?

HEADACHE OCCURENCE: *

- No pattern
- Usually at a specific time of the day

Do your headaches occur at specific times of the day?

HEADACHE FREQUENCY: *

- Daily
- A few times per week
- A few times per month
- Occasionally
- Rarely
- Once a month, associated with my menstrual cycle

How often do you experience headaches? Select the most appropriate option.

DAILY HEADACHE PATTERN: *

- Morning
- Middle of the day
- Evening
- Other

At what time of day do your headaches typically occur?

OTHER DAILY HEADACHE PATTERN: *

What time of the day or night do your headaches usually occur?

HEADACHE PAIN DESCRIPTION:

- Throbbing
- Constant
- Sharp
- Dull
- Other

Select all that apply to describe the pain experience.

HEADACHE PAIN DECERIPTION OTHER: *

Describe the headache pain type.

HEADACHE TRIGGERS: *

- No
- Yes

Have you noticed any triggers that may worsen your headaches?

HEADACHE TRIGGER DETAIL: *

What are your headache triggers?

NEUROLOGICAL CONDITIONS: *

- Yes
- No

Have you had any Neurological Conditions such as Stroke, Neonatal Encephalopathy, Headache, Migraine, ADHD, Dementias, Diabetic Neuropathy, Meningitis, Epilepsy, Neurologic Complications from Preterm Birth, Autism Spectrum Disorder, or Nervous System Cancers?

Dental Care & Neurological Conditions.

Neurological conditions can impact oral health and treatment. Conditions such as epilepsy, Parkinson's disease, multiple sclerosis, or stroke can affect muscle control, sensation, coordination, and overall oral function.

NEUROLOGICAL DISORDER: *

- Stroke
- Neonatal Encephalopathy
- Migraine
- ADHD
- Dementia
- Diabetic Neuropathy
- Meningitis
- Epilepsy
- Austism Spectrum Disorder
- Neurologic complications from preterm birth
- Nervous System Cancer
- Other

Select all that apply.

NEUROLOGICAL MEDICATION: *

- Yes
- No

Are you currently taking medication to treat a neurological disorder?

NEUROLOGICAL MEDICATION: *

Provide the name, dose, and frequency of the medication you are taking to treat a neurological condition.

OTHER NEUROLOGICAL CONDITIONS: *

Please provide details of other neurological condition(s) you have experienced or been diagnosed with.

BLOOD CONDITIONS: *

Have you been diagnosed with any blood diseases or disorders such as Leukemia, Lymphoma, Myeloma, Hemochromatosis, Hemophilia, Henoch-Schlein Purpura, Immune Thrombocytopenia, Iron-Deficiency Anemia, Pernicious Anemia, Venous Thromboembolism (Blood Clots), Hemophilia, Hereditary Hemorrhagic Telangiectasia (HHT), Sickle Cell Disease, Thalassemia, Vitamin K Deficiency Bleeding, or Von Willebrand Disease?

Blood Conditions

Dental treatments such as extractions, surgeries, or periodontal therapies may require modifications for patients with blood disorders to ensure optimal outcomes and minimise complications.

Dentists must consider these conditions when developing treatment plans to provide safe and effective care.

BLOOD CONDITION DETAILS: *

- I am taking medication for my blood condition
- Leukemia
- Anemia
- Von Willeibrand's Disease
- Excessive Bleeding
- Low Platelet Count
- Lymphoma
- Myeloma
- Hemochromatosis
- Hemophilia
- Henoch-Schönlein Purpura
- Immune Thrombocytopenia
- Iron-Deficiency Anemia
- Pernicious Anemia
- Venous Thromboembolism (Blood Clots)
- Hereditary Hemorrhagic Telangiectasia (HHT)
- Sickle Cell Disease
- Thalassemia
- Vitamin K Deficiency Bleeding
- Other Blood Condition

Please write the name of any other blood condition you have been diagnosed with.

BLOOD CONDITION MANAGEMENT: *

- Yes, I am taking medication or supplements
- Yes, I undergo treatment
- No, I do not receive any treatment or take medication/supplements

Are you undergoing treatment or taking any medication/supplements for your blood condition?

OTHER BLOOD CONDITION: *

Please write the name of your other blood condition.

BLOOD CONDITION MEDICATION NAME: *

Please write the name of the medication or supplement and the dose and frequency of your drug or supplements.

BLOOD CONDITION TREATMENT: *

Please give a brief description of the treatment you are undergoing for your blood condition.

STROKE: *

- Yes
- No

Have you ever had a stroke (sometimes called a brain attack)?

Stroke

A history of stroke may require special considerations during dental procedures, as certain medications, mobility issues, and cognitive impairments associated with stroke can impact dental care planning and the choice of treatments.

STROKE DATE: *

What is the year you had your last stroke?

STROKE PREVENTION:

- Yes
- No

Are you taking any medication or supplements for stroke prevention/management?

STROKE MEDICATION: *

Please write the medication or supplements name, does and frequency for Stroke prevention.

BLOOD-BORNE VIRUS: *

- No
- Yes

Have you been diagnosed with any blood-borne viruses, such as HIV, Hepatitis B, Hepatitis C, or another virus?

Blood-Borne Viruses

HIV / AIDS
Hepatitis B of C
Other Virus

Declaring your blood-borne viruses to your dentist is crucial to ensure proper precautions to prevent the spread of infections and provide tailored treatment, safeguarding your health and the dental team's well-being.

BLOOD-BORNE VIRUS NAME: *

- HIV / AIDS
- Hepatitis B
- Hepatitis C
- Other

Select the type of blood-borne virus infection you had.

BLOOD-BORNE VIRUS (OTHER): *

What other blood-borne virus have you had?

HEPATITIS C CARRIER: *

- Yes
- No

Are you a carrier of Hepatitis C, or have you been told that you can infect others?

HEPATITIS B CARRIER: *

- Yes
- No

Are you a carrier of Hepatitis B, or have you been told that you can infect others?

HIV / AIDS CARRIER: *

- Yes
- No

Are you a carrier of HIV / AIDS, or have you been told that you can infect others?

OTHER BLOOD-BORNE VIRUS: *

What other blood-borne virus(es) have you have had?

HIV / AIDS TESTING: *

- Within the last 6 months
- In the last 6-12 months
- In the last 12-24 months
- More than 2 years ago
- I do not remember

Have you been tested for HIV / AIDS? Select the most appropriate response.

HIV TEST TYPE: *

- Antibody tests
- Antigen/antibody test
- Nucleic acid tests (NAT)
- I do not remember

Select the type of HIV test you have most recently had.

HIV / AIDS TEST STATUS: *

- Positive
- Negative
- HIV-undetermined
- I do not remember

What was the result of your most recent HIV/AIDS test?

IMMUNE CONDITION:

- Yes
- No

Do you have an immune condition such as Addison disease, Celiac disease, Dermatomyositis, Graves disease, Hashimoto thyroiditis, Crohn's disease, Ulcerative colitis, Multiple sclerosis, Myasthenia gravis, Pernicious anemia, Reactive arthritis, Rheumatoid arthritis, Sjogren syndrome, or Lupus?

Immune Condition

Declaring your immune condition is critical to safeguarding your health.

IMMUNE CONDITION NAME: *

- Addison disease
- Celiac disease
- Dermatomyositis
- Graves disease
- Hashimoto thyroiditis
- Chron's disease
- Ulcerative colitis
- Multiple sclerosis
- Myasthenia gravis
- Pernicious anaemia
- Reactive arthritis
- Rheumatoid arthritis
- Sjogren's syndrome
- Lupus
- Other

Which immune condition(s) do you have?

OTHER IMMUNE CONDITION: *

What is the other immune condition you have?

IMMUNE MEDICATION: *

What medication or supplements are you taking to treat your immune condition?

CANCER: *

- No
- Yes

Have you ever had cancer?

Cancer

Specific cancer treatments, such as chemotherapy and radiation, can adversely affect oral health, including increased risk of infections, inflammation, and dental issues like dry mouth and mucositis.

CANCER RADIATION THERAPY: *

- No
- Yes

Have you had radiation therapy for cancer?

RADIATION THERAPY LOCATION: *

- Head, neck or jaws
- Other location

Did the radiation therapy involve the head, neck, or jaws?

RADIATION THERAPY FINISHED: *

In which month and year did you complete radiation therapy?

CANCER CHEMOTHERAPY: *

- No
- Yes

Have you had chemotherapy for cancer?

CHEMOTHERAPY STATUS: *

- Undergoing now
- Not currently undergoing chemotherapy

Make a selection to tell us more about your cancer chemotherapy history.

CHEMOTHERAPY STOPPED:

How many months has it been since you stopped chemotherapy for cancer?

CHEMOTHERAPY MEDICATION: *

What chemotherapy medications are you taking?

CANCER SURGERY: *

- No
- Yes

Have you had cancer surgery?

CANCER SURGERY LOCATION: *

What part of the body did you have cancer surgery on?

THYROID CONDITION: *

- Yes
- No

Do you have a thyroid condition, such as Hyperthyroidism, Hypothyroidism, Hashimoto's Thyroiditis, Thyroid Tumors, Postpartum Thyroiditis, Graves' Disease, Goiter or Thyroid Removal?

Thyroid Conditions

Thyroid disorders can impact oral health by causing symptoms like dry mouth, gum disease, and altered taste sensation.

THYROID CONDITION TYPE: *

- Hyperthyroidism
- Hypothyroidism
- Hashimoto's Thyroiditis
- Thyroid Tumours
- Postpartum Thyroiditis
- Graves' Disease
- Goitre
- Thyroid Removal
- Other thyroid condition

Select the thyroid condition that applies to you.

OTHER THYROID CONDITION: *

Provide some detail about your other thyroid condition.

THYROID TREATMENT: *

- Yes
- No

Are you receiving any treatment for your thyroid condition?

THYROID MEDICATION: *

- Yes
- Yes, but I have ceased taking the medication
- No

Have you taken any prescription medications or supplements for your thyroid condition?

THYROID MEDICATION: *

What is the thyroid medication or supplements do you take?

TUBERCULOSIS: *

- Yes, I have been in close contact with someone who has infectious tuberculosis
- No, I have not been diagnosed with tuberculosis

Have you had tuberculosis or recently been in contact with someone who has infectious tuberculosis?

TUBERCULOSIS TREATMENT: *

- No
- Yes

Are you taking any medication or supplements for the tuberculosis?

TUBERCULOSIS SYMPTOMS: *

- A cough that has lasted for more than three weeks, and is not improving
- Blood-stained sputum
- Fevers
- Night sweats
- Uunexplained weight loss
- Always feeling tired
- Loss of appetite
- None of the symptoms listed above are present

Have you experienced any of the above tuberculosis symptoms?

TUBERCULOSIS MEDICATION: *

What medication or supplements are you taking for Tuberculosis treatment?

DIABETES:

- No
- Yes

Do you have diabetes?

DIABETES TYPE: *

- Type 1
- Type 2
- Pre-Diabetic

What type of Diabetes do you have?

DIABETES MANAGEMENT:

- Medication
- Diet

How are you managing your Diatetes? Select all that apply.

DIABETES MEDICATION: *

What medication or supplements are you taking for your diabetes?

RHEUMATIC FEVER: *

- No
- Yes

Have you ever had rheumatic fever?

EYE CONDITION: *

- No
- Yes

Do you have an eye condition, or need to wear glasses for reading?

Eye Conditions

Informing your dentist about your eye conditions is essential as certain conditions may have implications for your dental care, such as assessing cosmetic dental work for approval.

EYE TREATMENT: *

- I need to wear glasses for reading
- I need to wear glasses for driving
- I am taking medication for my eye condition
- I am receiving no treatment for my eye condition
- Other eye treatment

Select all that apply.

OTHER EYE TREATMENT: *

Describe the other eye treatment.

EYE MEDICATION: *

What medication or supplements are you taking for your Eye condition?

SKIN CONDITION: *

- No
- Yes

Do you have any skin conditions such as Ichthyosis, Pachyonychia Congenita, Pemphigus, Psoriasis, Raynaud's Phenomenon, Rosacea, Vitiligo, or Scleroderma?

Skin Conditions

It is essential to inform your dentist about any skin conditions you are experiencing, as specific oral health issues may be linked to or impacted by skin conditions.

SKIN CONDITION NAME: *

Write the name or describe your skin condition?

SKIN TREATMENT: *

- No
- Yes

Are you taking any medication or supplements for your skin condition?

SKIN MEDICATION: *

Provide the name, dose, and frequency of skin condition medication or supplements.

Sleep

Snoring and sleepiness during the day can be a symptom of sleep apnoea. It can also impact oral health by increasing the risk of issues like dry mouth, tooth decay, gum disease, and tooth grinding.

SLEEP BREATHING: *

- Snoring has been observed
- Snoring has not been observed
- Mouth breathing has been observed
- Mouth breathing has not been observed
- Sleep breathing has not been observed by anyone
- Other observation

Select all that apply to breathing during sleep.

OTHER SLEEP BREATHING OBSERVATION: *

Please describe the other observations related to sleep breathing.

SLEEP STUDY: *

- Sleep apnoea has been diagnosed
- There is advice to have a sleep study conducted
- A sleep study has been planned
- A sleep study is being considered
- No sleep study was conducted or taken into consideration

Has a comprehensive sleep study been conducted or considered? Please select the response that best reflects your situation.

SLEEP DISTURBANCE SYMPTOMS: *

- Daytime sleepiness.
- Loud snoring.
- Witnessed episodes of stopped breathing during sleep.
- Waking unrefreshed
- Restless legs / Abnormal limb movements
- Insomnia
- Waking during the night and gasping or choking.
- Awakening in the morning with a dry mouth or sore throat.
- Morning headaches.
- Trouble focusing during the day.
- Mood changes, such as depression or being easily upset.
- Dry mouth
- None of the above

Do you experience any of the above symptoms? Select all that apply.

Sleepiness Check Needed!

Please complete the Epworth Sleepiness Scale below.

This scale helps assess your daytime sleepiness and can indicate a potential sleep disorder affecting your health and daily functioning. Completing the scale can provide valuable insights for diagnosis and treatment.

CHANCE OF DOZING AS A DRIVER WHILE STOPPED FOR A FEW MINUTES: *

- Enter 0 (zero) for a **ZERO** chance of dozing off. - Enter 1 (one) for a **SLIGHT** chance of dozing off. - Enter 2 (two) for a **MODERATE** chance of dozing off. - Enter 3 (three) for a **HIGH** chance of dozing off.

CHANCE OF DOZING DURING A LYING DOWN AFTERNOON REST: *

CHANCE OF DOZING OFF WHILE SITTING QUIETLY AFTER AN ALCOHOL FREE MEAL: *

CHANCE OF DOZING OFF SITTING & TALKING: *

CHANCE OF DOZING OFF AS A CAR PASSENGER ON A 1-HOUR OR MORE TRIP: *

CHANCE OF DOZING OFF SITTING INACTIVE IN A PUBLIC SETTING: *

CHANCE OF DOZING OFF WATCHING TV: *

CHANCE OF DOZING OFF SITTING & READING: *

Sleep Study

It is advised to have a sleep study conducted. Simple home-based sleep studies are available. Your dentist will discuss this with you. Click on the image below to learn more.

HOME-BASED SLEEP STUDY: *

- Yes, I am interested
- No, I am not interested
- No, I don't feel I need one

Would you like some information on how a home-based sleep study works?

SLEEP APNOEA CLASSIFICATION: *

- Severe
- Moderate
- Mild

What is your sleep apnoea diagnosis?

SLEEP STUDY REPORT: *

- I have a copy
- I do not have a copy
- I received a copy, but I have to locate it

Do you have a copy of your sleep study report?

Sleep Study Report Needed

Please find the report and bring it with you for your upcoming consultation.

Sleep Study Report Needed

Please request a copy of the sleep study report and bring it with you for your upcoming consultation.

SLEEP APNOEA RECOMMENDATION: *

- My doctor has recommended treatment to treat my sleep apnoea
- My doctor has not recommended treatment my sleep apnoea

Has the doctor managing your sleep apnoea recommended some treatment for your sleep apnoea?

SLEEP STUDY REPORT:

Drag & Drop Files, Choose Files to Upload

Upload your sleep study report, or take photos of the report and upload them here.

SLEEP APNOEA DEVICE USE: *

- Yes
- No

Are you using a device like a CPAP, custom-fitted mandibular advancement, or over-the-counter stop-snoring device?

SLEEP APNOEA DEVICE USED: *

- CPAP
- Other device

What is the device you use to treat your sleep apnoea and snoring?

OTHER SLEEP APNEA DEVICE: *

Describe the other device you use to treat your sleep apnoea and snoring. For example, a dentist-made, online, or over-the-counter device.

CPAP USE: *

- I have tried using a CPAP, but I am unable to wear it
- I do not like the idea of using one
- I use a CPAP, but I do not like wearing it
- I use a CPAP and have no problems with its use

How do you feel about wearing the CPAP? Select the best match answer.

Oral Snore/Sleep Apnea Appliance

If you dislike your CPAP machine or the idea of using one, we can provide a custom-made oral device like the one shown below.

Click here to learn more about this Australian-made appliance.

Other Health Matters

In this section, we request that you provide information on health-related topics not covered in previous medical health questions.

OTHER HEALTH CONDITION: *

- No
- Yes

Do you have any other health conditions that we have not covered above?

OTHER HEALTH CONDITION DETAIL: *

What other health condition(s) do you have? Please name the condition or give a brief description.

HOSPITILISATION: *

- No
- Yes

Have you ever been hospitalised?

Hospitalisation

Listing hospitalisations for your dentist is crucial as it provides vital insight into your overall health status and any treatments or medications you may have received.

HOSPITILISATION HISTORY: *

- Yes, within the last twelve months
- Yes, more than twelve months ago

Have you ever been hospitalised?

RECENT HOSPITALISATION REASONS: *

What was the reason for your most recent hospitalisation?

OTHER OPERATIONS/SURGERY: *

- No
- Yes

Have you had any operations or surgery not listed above?

OPERATIONS DONE: *

What was the operation, and what year did you have it done?

GENERAL ANAESTHETIC: *

- No
- Yes

Have you ever had a general anaesthetic (i.e., been put to sleep) for an operation or surgery?

GA - ADVERSE REACTION: *

- No
- Yes

Have you ever had a bad reaction to the drugs used during your general anaesthetic?

DISABILITY: *

- No
- Yes

Do you have any disabilities?

ORAL CARE IMPACT: *

- No
- Yes

Does your disability affect your day to day oral hygiene activity?

MOBILITY AID: *

- No
- Yes
- Ambulatory wheelchair user

Do you use a mobility aid?

ASSISTANCE NEEDED: *

- I do not need assistance to transfer from my mobility aid to the dental chair
- I need assistance to transfer from my mobility aid to the dental chair
- I need to have my dental care done while I am on my mobility aid

Select the most appropriate response.

Carer or Assistant Required

We apologise for any inconvenience this may cause. Still, due to Occupational Health and Safety (OHS) regulations, our staff cannot assist with transferring individuals from their mobility aids to the dental chair. Please bring a carer or assistant who can support the transfer to ensure your safety and comfort during the appointment. Your well-being is our top priority, and we appreciate your understanding and cooperation in this matter. If you have any questions or need further assistance, please contact us. Thank you for your understanding.

ALLERGIES: *

- Yes
- No

Are you allergic to anything?

Allergy Status

Declaring your allergies to your dentist is essential to prevent allergic reactions during dental procedures. This information allows your dentist to avoid potential allergens in treatments, choose suitable materials, and provide safe and personalised care tailored to your needs, ensuring a comfortable and risk-free dental experience.

DRUG ALLERGY: *

- Yes
- No

Are you allergic to any medications or drugs?

DRUG ALLERGIES: *

- Penicilin
- Iodine
- Procainamide
- Codeine
- Salicylates
- Barbiturate
- Heparin
- Meprobamate
- Procaine
- Sulfonamide
- Benzocaine
- Insulin
- Opiate
- Propoxycaine
- Thiazide
- Other

Select the drugs are you allergic to?

OTHER DRUG ALLERGY: *

What other drug(s) are you allergic to?

LATEX ALLERGY: *

- Yes
- No

Are you allergic to latex?

NICKLE ALLERGY: *

- Yes
- No

Are you allergic to nickle?

OTHER ALLERGY: *

- Yes
- No

Are you allergic to anything else not already mentioned above?

OTHER ALLERGIES: *

- Animal
- Food
- Stings
- Other

What other allergies do you have?

OTHER ALLERGY: *

What are the other things you are allergic to?

ANIMAL ALLERGY: *

What animals are you allergic to?

FOOD ALLERGY: *

What foods are you alergic to?

STING ALLERGY: *

What stings are you allergic to?

DENTAL MATERIAL ALLERGY: *

- Yes
- No

Are you allergic to dental materials, such as amalgam, chromium, or composite resins?

ALLERGY TO:

- Amalgam
- Chromium
- Composite resin
- Other material

What dental materials are you alergic to?

OTHER DENTAL ALLERGY: *

What other dental material are you allergic to?

HAY FEVER: *

- Yes
- No

Do you have hay fever?

HAY FEVER TREATMENT: *

- Yes
- No

Are you taking any medication to treat hay fever?

HAY FEVER MEDICATION: *

What medication or supplements are you taking for hay fever?

Other Medications

These items can harm oral health and influence our treatment plan to optimise it.

CHOLESTEROL TREATMENT: *

- Yes
- No

Are you taking any cholesterol-lowering medications?

CHOLESTEROL MEDICATION: *

What cholesterol-lowering medication or supplements are you taking?

WEIGHT LOSS MEDICATION USE: *

- Yes
- No

Are you taking weight loss medication or supplements?

WEIGHT LOSS MEDICATION TYPE: *

Provide the name, dose, and frequency of any weight loss medication or supplements you are taking.

OTHER MEDICATIONS: *

- Yes
- No

Are you taking other prescription medications, supplements, inhalers, and/or over-the-counter medicines you may not have listed in the previous sections?

OTHER MEDICATION TAKEN: *

- Yes, other prescription medication
- Yes, other non-prescription medication
- Yes, alternative medications or supplements

Do you take other prescriptions, supplements, or alternative medicines you may not have listed in the previous sections? Select all that apply.

OTHER PRESCRIPTION MEDICATION: *

What other prescription medications are you taking that you have not listed in the previous sections?

OTHER MEDICATION FOR: *

Why are you taking the other prescription medication?

OTHER MEDICATIONS FORMS: *

- Eye drops
- Ear drops
- Inhallers
- Puffers
- Creams or ointments
- Tablets

In what form are these non-prescription, supplements or alternative medicines being taken?

EYE DROPS: *

What eye drops are you taking? Please write the name of the medicine, dose, and frequency of use.

EAR DROPS: *

What ear drops are you taking? Please write the name of the medicine, dose, and frequency of use.

INHALLERS | PUFFERS: *

What inhallers or puffers are you taking? Please write the name of the medicine, dose, and frequency of use.

CREAMS | OINTMENTS: *

What creams or ointments are you taking? Please write the name of the medicine, dose, and frequency of use.

TABLETS: *

What tablets are you taking? Please write the name of the medicine, dose, and frequency of use.

Recent Medication

Informing your dentist about recently discontinued medications is crucial, as certain drugs can have lingering effects or interact with dental treatments.

RECENTLY CEASED MEDICINE: *

- No
- Yes

Have you recently stopped any medications or supplements in the past two months? Please share so we can ensure your dental care is safe and effective.

MEDICATION RECENTLY CEASED: *

- Painkillers
- Antibiotics
- Reflux medication
- Sleep medication
- Dry eyes medication
- Dry mouth medication
- Constipation medication
- Other not listed above

Please select any medications or supplements you’ve recently stopped. This helps us provide care that’s safe and supportive for you.

PAINKILLER: *

Please share the name, dose, and frequency of any painkiller you recently stopped, or let us know if you’re unsure. We’re here to support you.

ANTIBIOTIC: *

Please share the name, dose, and frequency of any antibiotic you recently stopped, or let us know if you’re unsure. We’re here to make this easy.

REFLUX MEDICINE: *

Please share the name, dose, and frequency of any reflux medication you recently stopped, or let us know if you’re unsure. We’re here to help.

SLEEP MEDICINE: *

Please share the name, dose, and frequency of any sleep medication you recently stopped, or let us know if you’re unsure. We’re here to support you.

DRY EYE MEDICINE: *

Please share the name, dose, and frequency of any dry eye medication you recently stopped, or let us know if you’re unsure. We’re here to assist.

DRY MOUTH MEDICINE: *

Please share the name, dose, and frequency of any dry mouth medication you recently stopped, or let us know if you’re unsure. We’re here to help.

CONSTIPATION MEDICINE: *

Please share the name, dose, and frequency of any constipation medication you recently stopped, or let us know if you’re unsure. We’re here to support you.

OTHER MEDICINE: *

Please share the name, dose, and frequency of any other medication you recently stopped, or let us know if you’re unsure. We’re here to make this easy.

MEDICATION LIST: *

- No
- Yes

Do you have a list of all the medications you take? Please let us know so we can ensure your care is safe and comprehensive.

MEDICATIONS LIST:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload or share a photo of your medication list. This helps us provide safe, personalised care, and we’re here to make it simple.

Your Health Choices

We’re here to support you without judgment. Sharing any past or current use of recreational substances helps us ensure your dental care is safe and effective, as these can affect your oral health.

SUBSTANCE USE: *

- No
- Yes
- Yes, but I have stopped
- Rather not say

Have you ever used recreational substances like marijuana or ecstasy? Please share, without worry, so we can provide care that supports your health.

SUBSTANCE TYPE STOPPED: *

- Marijuana
- Medically prescribed marijuana
- Cocaine
- Ecstasy
- MDMA
- Other
- Rather not say

Please select any recreational substances you’ve stopped using. Your honesty helps us provide safe, compassionate care.

SUBSTANCE TYPE IN USE: *

- Marijuana
- Medically prescribed marijuana
- Cocaine
- Ecstasy
- MDMA
- Other
- Rather not say

Please select any recreational substances you currently use. We’re here to support you with care and understanding.

OTHER SUBSTANCE STOPPED: *

Please share the name of any other recreational substance you’ve stopped using, or let us know if you’re unsure. We’re here to help without judgment.

YEAR SUBSTANCE USE STOPPED: *

Please share when you stopped using the substance, or let us know if you’re unsure. We’re here to support you.

Your Vaccination Status

We’re committed to your safety. Sharing your vaccination status helps us tailor your dental care to protect your health, ensuring treatments are safe and effective.

VACCINATION: *

- All vaccines are up-to-date
- I am not vaccinated
- Some vaccines are up-to-date
- Rather not say

Are your vaccinations, like flu or hepatitis B, up to date? Please share so we can provide safe, personalised care to keep you healthy.

DTaP VACCINE:

- No
- Yes

Is your diphtheria, tetanus, and pertussis (dTpa) vaccination up to date? Please let us know to ensure your dental care is safe and supportive.

INFLUENZA B:

- No
- Yes

Is your Haemophilus influenza type B vaccination current? Please share so we can provide care that keeps you safe and healthy.

HEPATITIS B:

- No
- Yes

Is your hepatitis B vaccination up to date? Please let us know to ensure your dental treatments are safe and effective.

POLIO:

- No
- Yes

Is your polio vaccination current? Please share so we can provide safe, compassionate care for you.

ROTAVIRUS:

- No
- Yes

Is your rotavirus vaccination up to date? Please let us know to support your health with safe dental care.

MEASLES, MUMPS, & RUBELLA:

- No
- Yes

Are your measles, mumps, rubella, or varicella vaccinations current? Please share to help us keep your care safe and effective.

INFLUENZA (FLU):

- No
- Yes

Is your annual flu vaccination up to date? Please let us know so we can ensure your dental care is safe and supportive.

MENINGOCOCCAL ACWY:

- No
- Yes

Is your meningococcal ACWY vaccination current? Please share to help us provide safe, personalised care.

HUMAN PAPILOMA VIRUS:

- No
- Yes

Is your HPV vaccination up to date? Please let us know to ensure your dental care is safe and effective.

PNEUMOCOCCAL:

- No
- Yes

Is your pneumococcal vaccination current? Please share so we can provide care that keeps you safe and healthy.

SHINGLES:

- No
- Yes

Is your shingles vaccination up to date? Please let us know to support your health with safe dental care.

OCCUPATION *

Please share your occupation. This helps us understand you better and provide care tailored to your lifestyle.

ALCOHOL DRINKER: *

- Yes
- No

Have you ever consumed alcohol? Please share so we can ensure your dental care is safe and supportive, without judgment.

Your Health Choices

We’re here to care for you without judgment. Sharing your alcohol use helps us ensure your dental treatments are safe and effective, as alcohol can interact with medications.

ALCOHOL CONSUMPTION: *

- Rather not declare it here
- Rarely
- Occasionally or on social gatherings
- Usually at mealtime
- Mostly on weekends
- Daily
- Quit drinking

Please choose the option that best reflects your alcohol consumption. We’re here to support your health with understanding and care.

WHEN:

Please share the year you stopped drinking alcohol, or let us know if you’re unsure. We’re here to support you.

SMOKING: *

- No, never smoked
- Quit
- Yes, currently smoking
- Yes, I want to quit

Have you ever smoked? Please share, without worry, so we can provide care that supports your health.

QUIT SMOKING IN:

Please share the year you stopped smoking, or let us know if you’re unsure. We’re here to help with care and understanding.

SMOKING ON: *

- Social occasions only
- Every day
- Rarely

Please share your smoking pattern. This helps us provide safe, compassionate care tailored to your needs.

VAPING: *

- No, never vaped
- Quit
- Yes, currently vaping
- Yes, I want to quit

Have you ever vaped? Please let us know, without judgment, so we can ensure your dental care is safe and supportive.

VAPING ON: *

- Social occasions only
- Every day
- Rarely

Please share your vaping pattern. We’re here to support your health with care and understanding.

QUIT VAPING IN:

Please share the year you stopped vaping, or let us know if you’re unsure. We’re here to support you.

QUIT SMOKING OR VAPING HELP: *

- Yes
- No
- Maybe

Would you like us to connect you with resources to help stop smoking or vaping? We’re here to support your journey with kindness.

Ensuring Your Information is Accurate

We’re grateful for your time in sharing your health history. Accurate information helps us provide safe, effective care tailored to you. If you think any answers need updating, please feel free to revise them before submitting. We’re here to support you.

Confirming Your Authority

Thank you for completing this form on behalf of someone else. Please confirm your authority to share their health information, as accurate details help us provide safe, caring treatment. If any answers need revising, feel free to update them before submitting. We’re here to help.

CARER AUTHORITY DECLARATION: *

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please review and check all statements to confirm your agreement. If you feel any answers need clarification with the dentist, kindly mark the last box. We’re here to support you.

PARTNER AUTHORITY DECLARATION: *

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please review and check all statements to confirm your agreement. If you think the dentist should clarify any answers, please mark the last box. We’re here to assist with care.

FOSTER CARER AUTHORITY DECLARATION: *

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and check all statements to confirm your agreement. If you feel some answers need discussion with the dentist, kindly mark the last box. We’re here to help.

GUARDIAN AUTHORITY DECLARATION: *

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please review and check all statements to confirm your agreement. If you think any answers need clarification with the dentist, please mark the last box. We’re here for you.

PARENT AUTHORITY DECLARATION: *

- I declare that I have the authority to complete this medical history form on behalf of the patient.
- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of providing accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please read and check all statements to confirm your agreement. If you feel some answers need discussion with the dentist, kindly mark the last box. We’re here to support you.

PATIENT DECLARATION: *

- I declare that I have the mental capacity to complete this medical history form.
- I understand the importance of accurate information.
- To the best of my knowledge and beliefs, all details provided are true and correct.
- Some details provided may need to be clarified by the dentist.

Please review and check all statements to confirm your agreement. If you think any answers need clarification with the dentist, please mark the last box. We’re here to care for you.

Signature *

Clear Signature

Your Thoughts Matter

We’re so grateful for your time and would love to hear how you found this questionnaire. Please share your experience, whether positive or negative, to help us make your future visits even better.

Thank you for your kind input!

QUESTIONNAIRE FEEDBACK:

- Not interested in providing feedback

If you prefer not to share feedback, please select this option. We respect your choice and are here for you.

CONVINIENCE RATING:

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Please rate how convenient this form was, from 1 star (very inconvenient) to 7 stars (very convenient). Your feedback helps us make your experience better.

USER-FRIENDLY RATING:

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Please rate how user-friendly this form was, from 1 star (not user-friendly) to 7 stars (very user-friendly). We value your thoughts to improve your experience.

FEEDBACK STATEMENT:

I had some difficulty completing the form,
Submitting my medical history online was convenient and saved me time in the practice waiting room!
Completing my medical history online allowed me to provide detailed information at my own pace.
Without a doubt, I find filling out the medical history form online to be the most accurate and efficient method, significantly reducing the need for paperwork during my visit.
I prefer to fill out the medical history form during my visit.

Please choose the statement that best reflects your experience with this form. Your insights help us make it easier and more supportive for you.

FEEDBACK COMMENT:

Please share any thoughts or feedback about your experience with this form. Your insights are precious to us and help us improve your care.

Welcome, First-Time Patients!

We’re thrilled to have you with us! After submitting this form, please complete the dental questionnaire to help us provide the best care for you.

Welcome Back, Returning Patients!

We’re so glad to see you again. If you’re here for issues like pain, swelling, or a broken filling, please complete the dental questionnaire after submitting this form to help us care for you.