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Home
About
About
Hi! From Dr PY
Paediatric Dentistry
Paediatric Dentistry
First Dental Visit
Prevention
Treatments
Children with Special Needs
Happy Gas - (RA)
General Anaesthesia (GA)
Orthodontics
Orthodontics
Children Orthodontics
Adult Orthodontics
Orthodontics for New Patients
Orthodontics FAQ
Parents Info
Important Information
Fees
New Patients- Paediatric Dentistry
Continuing Patients and Home Care
Your Rights as a Patient
Resources
Medical History Form
Orthodontics - Medical History
Forms
FAQ COVID-19
Referral
Locations
Feedback
My Braces
CONTACT US
FORMS
Medical History - Orthodontics
Please complete prior to appointment.
Patient's Details
The information you provide is confidential and will be handled in accordance with our Privacy Policy. More information available
Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Female
Male
Other
Address 1
*
Address 2
Suburb
*
Postocde
*
State
*
Phone
*
Email
*
Parent/Guardian Information
Parent/Guardian 1 Name
*
Mothers Name
First Name
Last Name
Relationship to Child
Mobile Phone
Home Phone
Work Phone
Email
Parent/Guardian 2 Name
*
Fathers Name
First Name
Last Name
Relationship to Child
Mobile Phone
Home Phone
Work Phone
Email
Health Insurance and Medicare Details
Do you have health insurance?
*
Yes
No
If yes please specify
Do you have dental cover?
Yes
No
Do you have hospital cover?
Yes
No
Are you eligible for Medicare's $1000 Child Dental Benefit Scheme?
A child can get CDBS when: - they are eligible for Medicare - they are between 2 and 17 years old for at least 1 day that year. - a parent or child get an eligible payment at least once that year from centrelink PLEASE BE AWARE WE DO NOT BULK BILL.
Yes
No
Unsure
Dental History
Who referred you to this practice. Practice Name?
Who referred you to this practice. Dentist Name?
When did you last see a dentist?
Did you have any x-rays taken at the dentist?
*
Yes
No
Reason for this appointment?
Have you had previous dental treatment?
Have you had any traumatic experiences with the dentist or doctor?
Do you have any toothache at the present?
Yes
No
Medical History
Height?
Weight?
Have you ever had any of the following?
*
Rheumatic Fever
Excessive Bleeding
Asthma
Epilepsy
Persistent Cough/Bronchitis
Heart Problems
Hepatitis
Sleep Apnoea
None of the above
Do have any other conditions?
*
(eg Down Syndrome, ADHD, Autism, Developmental or Behavioral issues )
Yes
No
If yes please specify
Do you have any allergies? (e.g. Penicillin, aspirin, latex )
*
Yes
No
If yes please specify
Are you presently receiving medical attention?
*
Yes
No
If yes please specify
Are you presently taking any medication?
*
Yes
No
If yes please specify
Have you ever been hospitalised?
*
Yes
No
If yes please specify
Have you ever had a general anaesthetic?
*
Yes
No
If yes please specify
Have you or anyone in your family had a bad reaction to a general anaesthetic?
*
Yes
No
If yes please specify
Are you taking fluoride tablets?
*
Yes
No
Have you ever sufferred from truama to your teeth or jaw?
*
Yes
No
If yes please specify
Do you suffer from pain to the jaw joints?
*
Yes
No
If yes please specify
Are you participation in in any contact sports?
*
Yes
No
If yes please specify
Have you previously had orthodontic treatment?
*
Yes
No
If yes please specify
*
Have you undergone a sudden increase in height recently?
*
Yes
No
FEMALE PATIENTS - Have you started menstruation?
Yes
No
Declaration
*
I (Patient/Parent/Guardian) acknowledge that the above information is accurate and i will advise my dentist of any changes to the above information in the future.
Thank you!