Medical History Form

Patient's Details

The information you provide is confidential and will be handled in accordance with our Privacy Policy. More information available

First Name

Last Name

Date of Birth

Gender

Male Female Other

Address 1

Suburb

Postcode

State

Phone

Are you of Aboriginal or Torres Strait Islander origin?

Yes No

Parent/Guardian Information

Parent/Guardian 1 Name

First Name

Last Name

Relationship to Child

Phone

Parent/Guardian 2 Name - If not applicable, please write NA

First Name

Last Name

Phone

Relationship to Child

Health Insurance and Medicare Details

Which best describes your level of private health insurance?

Hospital and Extras Hospital only Extras only No private health insurance

Name of Health Insurance Fund:

Medicare Number

Medicare Reference Number:

Medicare $1000 Child Dental Benefit Scheme

To be eligible for the Child Dental Benefit Scheme (CDBS), a child must be aged 0–17, eligible for Medicare, and receive a government payment like the Family Tax Benefit Part A.

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

Are you eligible for Medicare's $1000 Child Dental Benefit Scheme?

Yes No Unsure

Child Safety & Social / Legal Circumstances

Please read before answering:
The following questions relate to your child’s social or legal circumstances. This information is optional, confidential, and will only be used to ensure safe and appropriate care for your child. If you prefer not to answer certain questions, you may skip them.

1. Child Protection / Child Safety

Is the child currently under the care or guardianship of a child protection or child safety agency?

Yes No

If Yes, please state name of agency :

Is there a caseworker or contact person we should be aware of?

Name

Role

Phone

2. Court Orders / Legal Orders

Are there any court orders currently in place regarding the child? (e.g. custody orders, family court orders, child safety orders, protection orders)

Yes No

If Yes, please indicate what type of order (e.g. custody, supervision order, protection order) and any name or reference:

Do we — the dental clinic — need to be aware of any restrictions on who can bring the child, make decisions for the child, or give consent for treatment?

Yes No

If Yes, please email a copy of the court order to [email protected]

3. Family / Household Safety

Are there any family safety concerns, domestic-violence circumstances, or other social circumstances within the home or household environment that we should know about in order to provide safe and appropriate care for the child?

Yes No Prefer not to say

If Yes and you are comfortable, please provide brief details (or write “Prefer to discuss privately”).

Dental History

Who referred you to this practice. Practice Name?

Who referred you to this practice. Dentist Name?

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?

Medical History

Height?

Weight?

If other 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

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.

Signature

Use of Artificial Intelligence (AI) in Clinical Documentation

Our practice may use secure AI-assisted tools to support clinical documentation, including transcription of consultations and preparation of clinical notes and correspondence. These tools may process information discussed during your appointment. All information is handled in accordance with Australian privacy laws.

By signing below, you consent to the use of AI-assisted technology for these purposes.

I consent I do not consent

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