Welcome to Wholistic Dentistry Please fill and submit the following form prior to attending your appointmentMedical history formΔ Wholistic Dentistry PH: (02) 6297 88386/2 Rutledge StreetQueanbeyan NSW 2620www.wholisticdentistry.com.au[email protected]Thank you for choosing our practice.In order to serve you properly we will require the following information. All information will be strictly confidential.Choose: MR MST MRS MS MISSFirst NameLast NameAddress:CityStatePostcodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweDate of birth:EmailHome Phone:Mobile:Work:Occupation:Do you have private health insurance? If yes, which fund?Next of kin (Name and Phone Number):Emergency contact other than next of kin (Name and Phone Number):What is your reason for coming to the surgery?Whom may we thank for referring you?What is the name of your medical practitioner?Name the medicines or drugs you have taken in the past year?Are you allergic to penicillin, or any other drugs or medicines? Please specify.Have you ever had excessive bleeding requiring special treatment? YES / NOBEFORE YOU GO TO THE NEXT SECTION, PLEASE REMEMBER WE RESPECT YOUR PRIVACY.IF YOU WOULD PREFER TO SPEAK WITH THE DENTIST, THIS IS YOUR RIGHT AND ANYTHING YOU DISCLOSE IS STRICTLY CONFIDENTIAL.SELECT ANY OF THE FOLLOWING YOU HAVE HAD OR SUFFER ALL THE TIME WITH: Diabetes Tuberculosis Headaches Asthma Stroke Epilepsy Clicking mandible Shoulder pain Ankle pain Neck pain Backaches Cough Mental health problems Blood transfusion High blood pressure Heart mumur Heart trouble Congenital heart lesions Anaemia Jaundice Hepatitis AIDS Mouth ulcers Cold soresHave you ever had any serious illness? YES/NO, Please specify.Are you pregnant now? YES/NO If YES number of weeks or months?YOUR DENTAL HISTORYHow long has it been since you have seen a dentist?What was done?Did you have any X-rays?How often did you visit the dentist before then? How often do you brush your teeth? How often do you replace your toothbrush? Do you use dental floss? If yes, how often?Do you have bleeding gums?Does food wedge between your teeth? Do you grind or clench your teeth? I UNDERSTAND PAYMENT IS REQUIRED AT THE SAME TIME OF TREATMENT. I ALSO ACKNOWLEDGE THIS SURGERY DOES NOT DO ACCOUNTS.Date / TimeMask InputSubmit Form
