Confidential Medical and Dental History

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It is important for the Dentist to know details about your medical history as this could affect the success of your dental treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the reverse of this form.

Personal Details

Title: Dr Mr, Mrs, Ms _______ First name(s): ____________________ Last Name: _________________________

Preferred Name: ____________________ Date of birth: ________________ Health Fund: Yes / No Fund Name _________

Home address: ________________________________________________________________________________

Postal address: __________________________________________Occupation: ______________________________________

Ph (hm): ___________________________Ph (wk):_________________________ Mob:_______________________

Email: _____________________________________

Name of emergency contact person: ______________________________ Phone No: _______________________

General Practitioner’s name: ____________________________________ Phone No: _______________________
Medical History

I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist. Yes / No

Are you receiving any medical treatment at the present time? Yes / No

Details: ________________________________________________________________________________

Have you been hospitalised in the last 12 months? Yes / No

Have you had any abnormal reactions to local or general anaesthesia? Yes / No

Do you require antibiotic cover before dental treatment? Yes / No

Please list current medications: __________________________________________________________________________

Please list any medications or drugs you are allergic to: _______________________________________________________

Please list all other known allergies (eg latex, foods): __________________________________________________________

Do you smoke? Yes / No How many per day?_________ Are you pregnant? Yes / No How many months? _____

Do you have, or have you ever had any of the following medical conditions? If so please tick as appropriate:

Low / High Blood Pressure

Severe Headaches


Steroid Therapy

Kidney Disease

Prosthetic Implant (Heart, Hip)

Rheumatic Fever

Excessive Bleeding / Bruising

Cardiac Pacemaker



Stomach or Digestive Conditions



Hepatitis / Liver Disease

Radiation Therapy


Contact with blood-borne viruses

Heart Complaints

Thyroid Disease

Bronchitis / Emphysema

Osteoporosis / Bone Disease

Nervous / Psychiatric Condition

Anaemia / Blood Diseases


Drug Dependence

Other conditions not listed:

Dental History

Approximate date of last dental visit ____________________ Name of last Dentist _________________________________

Do you currently have dental pain? Yes / No Do you become anxious when having dental treatment? Yes / No
How did you hear about us?

Yellow Pages Yes / No Newspaper Advertisement? Yes / No Internet Search Yes / No

Patient or Friend Yes / No (Please include their name so we can thank them ______________________________)

I have read and accept the privacy policy attached: Patient / Guardian Signature Date

Adentica Family Dentists

Patient’s Rights and Responsibilities

At Adentica Family Dentists we believe that your dental care is a partnership between you and your dentist. Our Adentica Team is here to support you and the dentist to achieve a quality outcome. Mutual respect and open communication will ensure that your dental experience is empowering and one which you feel comfortable to recommend.

Our promise to you:

Safety You will receive safe and high quality dental care, provided with professional care, skill and competence.

Respect The care provided will show respect to you, your culture, beliefs, values and personal characteristics.

Communication You will receive open, timely and appropriate communication about your dental care and treatment options in a way you can understand. You are encouraged to join in the decision making and ask questions to seek clarification.

Privacy Your personal privacy will be maintained and proper handling of your personal health and other information is assured. Your information will be shared should you agree to referral for Specialist treatment.

Feedback We look forward to receiving your feedback. Please direct feedback to your Dentist or the Practice Manager.

Financial As part of our partnership we expect that you will finalise your account at the end of each treatment session. You will be provided with a treatment plan outlining our fees for any treatment recommended after your exam and clean. Please seek clarification from our Practice Manager of Receptionist if you have questions regarding payment.

Adentica Medical / Dental History (Reference ADAQ) Cnr Mayes Avenue & Third Avenue, Caloundra Q 4551

Ph (07) 5438 2225 Fax (07) 5438 2228

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