Skip to content
(03) 9417 2023
contact@cwdp.com.au
21 Victoria Parade,
Collingwood VIC 3066
Facebook
Instagram
Mandarin multilingual support is now available. | Mandarin multilingual support is now available. | Mandarin multilingual support is now available. | Mandarin multilingual support is now available. |
Home
Our Team
Services
Implants
Mouthguards
Resin and Ceramic Fillings
Scale and Cleaning
Clear Aligners
Teeth Whitening
Wisdom teeth
Offers
Dental New Patient Offer
CDBS Offer
Returning Clients Offer
Dental Plans with Afterpay
Medical History Form
Cancellation Policy
Blogs
Contact Us
Home
Our Team
Services
Implants
Mouthguards
Resin and Ceramic Fillings
Scale and Cleaning
Clear Aligners
Teeth Whitening
Wisdom teeth
Offers
Dental New Patient Offer
CDBS Offer
Returning Clients Offer
Dental Plans with Afterpay
Medical History Form
Cancellation Policy
Blogs
Contact Us
Book Appointment
Book Now
Home
Our Team
Services
Implants
Mouthguards
Resin and Ceramic Fillings
Scale and Cleaning
Clear Aligners
Teeth Whitening
Wisdom teeth
Offers
Dental New Patient Offer
CDBS Offer
Returning Clients Offer
Dental Plans with Afterpay
Medical History Form
Cancellation Policy
Blogs
Contact Us
Home
Our Team
Services
Implants
Mouthguards
Resin and Ceramic Fillings
Scale and Cleaning
Clear Aligners
Teeth Whitening
Wisdom teeth
Offers
Dental New Patient Offer
CDBS Offer
Returning Clients Offer
Dental Plans with Afterpay
Medical History Form
Cancellation Policy
Blogs
Contact Us
Medical History Form
Home
Medical History Form
Please complete the following confidential questionnaire, which will assist us in providing you with quality dental care
Please Select
Mr
Mrs
Ms
Miss
Dr
Surname
*
Name
*
Address
*
Postcode
*
Phone Home
*
Work
Mobile
*
Email
*
Date of Birth
*
Occupation
Parent/Guardian names if under the age of 16
Are you in a Private Health Fund for Dental ?
Yes
No
If yes, which one ?
Are you covered by Veterans Affairs ?
Yes
No
If yes, card number?
How did you find out about Our Practice?
Advertising
Family & friends
Internet
Walk-in/Seen the sign
Yellow Pages
Other
Have you ever had or do you have any of the following? (Please tick)
High Blood Pressure
Yes
No
Diabetes
Yes
No
Heart Conditions or Heart Surgery
Yes
No
Artificial heart valve
Yes
No
Damaged heart valve
Yes
No
Penicillin allergy
Yes
No
Latex allergy
Yes
No
Kidney disease
Yes
No
Arthritis
Yes
No
Excessive Bleeding
Yes
No
Asthma or Bronchitis (Which one?)
Yes
No
Rheumatic Fever
Yes
No
HIV or Hepatitis A,B or C (Which one?)
Yes
No
Hip/Knee Replacement (Which one?)
Yes
No
Epilepsy
Yes
No
Anxiety or Depression (Which one?)
Yes
No
Hay Fever or Sinus
Yes
No
Allergies
Yes
No
Ladies, are you pregnant?
Yes
No
Radiation therapy to the head or neck
Yes
No
Treatment therapy for cancer
Yes
No
Do you get headaches?
Yes
No
Do you breathe through your mouth?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you snore?
Yes
No
Would you like to improve the colour of your teeth?
Yes
No
Are you happy with your smile?
Yes
No
Would you like to straighten your teeth or improve the appearance?
Yes
No
Do you snore or have sleep apnoea?
Yes
No
Have you taken bisphosphantes?
Yes
No
Tuberculosis
Yes
No
Any other serious illnesses not mentioned
Yes
No
Do your gums bleed when brushing?
Yes
No
Are your teeth sensitive to hot or cold when brushing?
Yes
No
Are you, or do you identify as:
Aboriginal
Torres Strait Islander
Both
Neither
Prefer not to say
What is the reason for your visit today?
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:
Are you currently taking any medications?
GP's Name and location:
Signature :
Date
Click here to agree to our privacy policy
Submit
