Confidential Patient Questionnaire and Medical History

Please complete all relevant sections. Fields marked with * are required.

Patient Details

Title First Name * Surname * Gender Date of Birth * Home Address Suburb Post Code State Occupation Home Phone Work Phone Mobile Phone * Email

Name Contact Number Relationship Doctor Doctor's Contact Number

Tick where applicable

Other

Name of current / last dentist

Approximate date of last dental check up

Do you have a dental problem at present?

Do you become anxious or uncomfortable when receiving dental treatment?

How do you think you / the patient will react to treatment?

Where did you hear about us?

All staff recognise and support the patient's right to confidentiality of all treatment, personal history and records.

Patient / Parent Signature (full name) * Date