Login Retrieve my history NEW PATIENT INFORMATION | 2024 Information about your medical history is essential for providing safe and effective dental treatment. Please take the time to complete this form as accurately as possible. Where you are unsure please discuss with your dentist. Title: *Please selectMr.Ms.Mrs.Miss.Dr.First name: *Family name: *DOB: *Email: *Contact ph: *Address: *Suburb: *Postcode.: *Emergency contact / Next of kin:Title:Please selectMr.Ms.Mrs.Miss.Dr.First name:Family name:Contact ph:Relationship:Name of medical GP:DrContact ph:Please list any other known allergies (e.g. latex, foods, preservatives, drugs or medicines etc):What is your primary reason for seeing Dr Cipriani?Please include your goals for the short term and, even, your desires over the long term (whether you think these are achievable or otherwise).Have you ever noticed any changes to your bite or jaw joint? Yes No 1. Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping)2. Do you feel like your lower jaw is being pushed back when you bite your teeth together?3. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars or other hard, dry foods?4. Have your teeth changed in the last 5 years, become shorter, thinner or worn?5. Are your teeth becoming more crooked, crowded, or overlapped?6. Are your teeth developing spaces or becoming more loose?7. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?8. DO you place your tongue between your teeth or close your teeth against your tongue?9. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?10. DO you clench your teeth in the daytime or make them sore? 11. Do you have any problems with sleep (i.e restlessness), wake up with a headache or an awareness of your teeth?12. Do you wear or have you ever worn a bite appliance? Have you ever been diagnosed with or received treatment for any of the following? Select No for all Heart condition e.g. angina, heart attack, by-pass operation, open heart surgery, arrhythmia, pacemaker, heart valve surgery, heart murmur Yes No Blood pressure e.g. high or low Yes No Lung condition e.g. bronchitis, asthma, emphysema, pulmonary embolism, pneumonia Yes No Liver disease e.g. hepatitis, jaundice Yes No Kidney disease e.g. kidney failure, dialysis, infection, kidney stones Yes No Bone disease e.g. osteoporosis, Paget’s disease, arthritis, hip/knee/joint replacement Yes No Gastrointestinal, Stomach or digestive condition e.g. stomach or peptic ulcer, reflux, Crohn’s disease, Colitis, Yes No Stroke Yes No Nervous or psychiatric condition e.g. anxiety, depression, schizophrenia, ADHD, Yes No Epilepsy or seizures Yes No Blood disorders e.g. anaemia, leukaemia, excessive bleeding, Von Willebrand’s disease, Haemophilia, low platelet count Yes No Blood-borne viruses e.g. HIV, viral Hepatitis, Yes No Immune conditions (steroid therapy) Yes No Cancer (chemotherapy, radiotherapy) Yes No Thyroid Yes No Diabetes Yes No Eye condition e.g. Cataracts, glaucoma Yes No Skin condition Yes No Tuberculosis, Rheumatic fever, or Any other condition? Yes No Current MedicationsPlease list all medications you are taking and the reason you take them. Please include all over-the-counter, prescription, herbs, vitamins etc.Is there anything else that you would like to let us know in respect of your care and safety?Do you consent to the use of photographs and videos for educational / treatment samples? Yes No How did you hear about our practice: Google Walk by Friend/Family Social Media Consent to treatment I hereby authorise the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make an appropriate diagnosis. I agree to the use of an anaesthetic, sedatives and other medication as necessary. I will always be informed of any potential medication prescribed. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service. In the event that you need to reschedule or cancel an appointment, we require a minimum notice of 2 business days. Failure to provide notice will incur cancellation fees in line with the appointment duration. To the best of my knowledge, the questions on the form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental practice of any changes in medical status. Patient signature * Signature confirmed Clear Date: * Reset Submit
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