Medical History Form

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Name
Title
Phone
Email Address
Gender
Occupation
Name of Health Fund
Date of Birth
Dental Cover
Hospital Cover
Allergies
Referring Dentist/Doctor
Referring Dentist/Doctor's Address
General Medical Practitioner
General Medical Practitioner's Address
Have you ever had?
Heart Trouble
Rheumatic Fever?
High Blood Pressure?
Chest Pain?
Excessive bleeding needing special treatment?
Fits or Epilepsy?
A Stroke?
Asthma?
Bronchitis or Lung Disease?
Arthritis?
Diabetes?
Thyroid Trouble?
Kidney Trouble?
Hepatitis, Liver Trouble, or HIV Infection?
Stomach or Bowel Problems?
Skin Problems?
Osteoporosis, Bone Cancer, Paget's Disease or Multiple Myeloma?
Have you ever taken any Bisphosphonates or equivelant Medications? eg) Fosamax, Actonel, Alendronate, Zometa?
Any Other Medical Problems? Please Specify
Have you been hospitalised for any reason including anaesthetics? Please Specify
Have you have any radiotherapy of the head or neck? Please Specify
Are you currently taking medication? Please Specify
Do you smoke? If yes how many per day?
Do you drink alcohol? If yes how much per day?
Are you pregnant?
Is there any other relevant information that you may wish to discuss with the doctor?
I would not like information given to...