Medical History Form - Specialist Endo Sydney

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Home
About
- Cases
- Overview
- Team
- FAQs
  - For Patients
  - For Clinicians
Services
- Cracked Tooth Treatment
- Advanced Canal Location
Blog
Contact
- Referral Form
- Medical History Form

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Medical History Form

By submitting this form, you confirm that you have read and understood our Privacy Policy and consent to the use of your health information in this way.

PATIENT NAME:

DOB:

GENDER:

ADDRESS:

ADDRESS:

ADDRESS:

PHONE:

EMAIL:

DO YOU HAVE PRIVATE HEALTH INSURANCE:

YES NO

NAME OF HEALTH FUND:

MEMBER NUMBER:

NUMBER NEXT TO NAME:

MEDICARE CARD NUMBER:

REFERENCE #:

EXP DATE

This is a confidential questionnaire and is necessary with regard to medicines used in dentistry as well as oral complications of illnesses and medications.

How is your general health?

GOOD AVERAGE FAIR POOR

Have you had or are you being treated for any of the following?

Heart trouble

YES NO

High blood pressure

YES NO

Stroke

YES NO

Rheumatic fever

YES NO

Hepatitis B or C

YES NO

Diabetes

YES NO

Heart murmur

YES NO

Asthma

YES NO

Tuberculosis

YES NO

Depression

YES NO

HIV/AIDS

YES NO

Epilepsy

YES NO

Liver or kidney problems

YES NO

Anaemia or other blood problems

YES NO

Pacemaker

YES NO

Are you a smoker? If yes how many per day?

Have you had any other medical condition other than those listed previously? If so, please give details.

Who is your medical doctor (GP)? GP NAME:

GP SUBURB:

GP PHONE:

Are you taking any medications at the moment? Please give details:

Are you allergic to any medications or to latex rubber? Please give details:

Have you ever taken?

Zometa Actonel Boniva Fosamax Pamisol Aredia Didronel Bonefos Skelid Prolia

Have you ever had radiotherapy of the head and neck?

YES NO

Have you had a blood transfusion in the past 10 years?

YES NO

Are you pregnant?

YES NO

EMERGENCY CONTACT DETAILS

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE:

To avoid a cancellation fee, the practice requires two business days notice if an appointment cannot be attended. We will endeavour to help patients by making a courtesy call or sending a mobile text message, two days before the appointment. This service is for courtesy only and it is the patient’s responsibility to remember the appointment. A cancellation fee will apply with cancellations not made in accordance to our policy.
I hereby state the information in this form above is accurate, and I agree to the cancellation policy

Patient or Guardians’ signature:

Your Trusted Sydney Endodontist

Gentle, stress-free endodontic care in Sydney—whether it’s root canal therapy or specialist treatment, we’re here to save your natural teeth and keep you comfortable.

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Level 3, Suite 301/34 Hume St, Crows Nest NSW 2065
[email protected]
(02) 9129 0009

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