Adult Information

ADULT PERSONAL DETAILS

Last Name

First Name

Sex

D.O.B.

Address

Suburb

Postcode

Phone Number (Home)

Phone Number (Mobile)

Email

Occupation

Employed by

Dentist's name

Doctor's name

Payee's Name (person responsible for payment of account):

Payee's Address

Payee's Suburb

Payee's Postcode

HEALTH FUND

WHO REFERRED YOU TO US?

MEDICAL HISTORY

Do you have any health problems?

If yes, please list

Is there any history of serious illness, accident or operation?

If yes, please list

Are you under a doctor's care for any problem at this time?

If yes, please list

Are you taking any medication?

If yes, please list

Do you have any allergies or drug sensitivities?

If yes, please list

DENTAL HISTORY

Have you had an orthodontic consultation previously?

If yes, please give details

Have you had any previous orthodontic treatment?

If yes, please give details

Have you ever had any injuries to the face, mouth, teeth or chin?

Have you ever been informed of any missing or extra permanent teeth?

Have you had any cyst or tumour of the jaws or gums?

Have you had ever experienced pain or discomfort in the jaw joint?

Have you ever had gum problems?

Do you brush your teeth daily?

Do you floss your teeth daily?

Do you have any of the following habits?

Clenching/Grinding

Nail Biting

Mouth Breathing

Lip Sucking/Biting

Tongue Thrusting

Thumb/Finger Sucking

Sports drinks

Smoking

Reason for seeking orthodontic treatment:

MEDICAL CHECKLIST

Arthritis

Asthma

Fainting or dizziness

Bleeding disorders

Bone disorders

Heart disease or murmur

Hepatitis

HIV+/AIDS

Cleft palate

Kidney/Liver Problems

Rheumatic/Scarlet Fever

Sinus Problems

High/Low Blood Pressure

Learning disabilities

Speech problems

Cancer or tumour

Convulsions/Epilepsy

Diabetes

Hearing problems

Endocrine problems

Emotional problems

Syndromes

Operations

Tuberculosis

Frequent headaches

Snoring

I understand that the information I have provided is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

I accept the terms & conditions

8/3 Rosewood Drive

Rural View, Mackay 4740

(07) 4840 2832

Call us today!

Opening Hours

Mon - Fri: 8:00 - 17:00