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171 Acland St, St Kilda VIC 3182
(03) 9534 8611
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CROWN & BRIDGE
ROOT CANAL
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Home
Our Services
GENERAL DENTISTRY
PERIODONTAL
CROWN & BRIDGE
ROOT CANAL
MINIMALLY INVASIVE (MI) DENTISTRY
COSMETIC DENTISTRY
TEETH WHITENING
VENEERS
STRAIGHTENING TEETH
DIGITAL SMILE DESIGN
TOOTHACHES
PAIN MANAGEMENT
EMERGENCY TREATMENT COSTS
OTHERS
WISDOM TEETH
DENTAL IMPLANTS
Reviews
Contact
About Us
Search
Search
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Medical History Questionnaire
[contact-form-7 id=”263″ title=”Medical History Form”]
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Name
Contact Number
Email
Message
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Medical History Questionaire
Title
----Please select An Option----
Mr.
Ms.
Mrs.
Other
First name
Surname
Date of Birth
Mobile Number
Email
Home address
2nd address
Postal address
Emergency contact name
Emergency contact number
Relationship
Medical Doctor
Medical Doctor Address
Medical Doctor Contact Number
How did you hear about us:
---Please choose an option---
Google
Website
Walk by
Yellow Pages
Advert
Referred by your GP
Personal referral
Do you suffer from any of the following?
High blood pressure
Heart ailment
Rheumatic fever
Asthma, chest or breathing problems
Tuberculosis
Stomach or bowel problems (eg ulcer)
Kidney disease
Diabetes
Depression (needing medication)
Excessive bleeding or blood disorder
Epilepsy
Hepatitis
AIDS/HIV
Osteoporosis or bone tumor
Do you smoke:
--Please choose an options--
No
Yes
Would you like to discuss these questions in private with the dentist?
--Please choose an options--
No
Yes
Do you have an artificial hip, heart valve or other prosthetic implant?
--Please choose an options--
No
Yes
Have you ever had problems with dental treatment?
--Please choose an options--
No
Yes
Are you taking any drugs, medicines or tablets?
--Please choose an options--
No
Yes
Female patients, are you pregnant?
--Please choose an options--
No
Yes
Do you have allergies?
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