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Dr Jacob de Looze
Oral and Maxillofacial Surgeon

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07 3395 0099

TEETH : JAW : APNOEA : IMPLANTS

Patient Medical History Form

Please fill out the following form for your upcoming appointment.

Personal Details

Title

First Name

Last Name

Date of Birth

Home Phone Number

Mobile Phone Number

Home Address

Email

Carer / Next of Kin Full Name

Carer / Next of Kin Contact

Relationship

Patient Medicare Number

Patient Reference Number

Expiry Date

Insurance Details

Do you have PRIVATE HEALTH Insurance? *

No

Yes

Name of Private Health Fund

Membership Number (put N/A if no cover)

Do you have EXTRAS COVER? *

Yes

No

Do you have hospital cover? *

Yes

No

Unsure

What Level of Cover do you have? *

GOLD

SILVER

BRONZE

BASIC COVER

NO COVERAGE

Do you have coverage under VETERANS AFFAIRS (DVA) ? *

No

Yes

GOLD / WHITE Card Holder

GOLD

WHITE

Veterans Affairs Number

Are You Covered Under Workers Compensation for this Treatment? *

No

Yes

Workers Compensation Number

Case Manager Name (if Known)

Medical Details

General Practitioner Name

Practice Name or Address

Who is your GENERAL DENTIST?

Practice Name / Address

Have you had an x-ray / CT scan of your mouth / face in the past 12 months? *

Yes

No

Where did you have this x-ray (or other) taken?

Are you under the care of a Medical Specialist? (Eg: Cardiologist / Oncologist / Haematologist) PUT DOCTOR NAME AND LOCATION OF PRACTICE.

Condition Being Treated

Please add an additional information about this or other Specialists you may see

Have you been diagnosed with any of the following conditions?

Heart Disease / Surgery *

Yes

No

Cancer *

Yes

No

Type?

Have you ever had any of the following treatments? *

Radiotherapy

Chemotherapy

Immunotherapy

No

Heart Attack *

Yes

No

Stroke *

Yes

No

Bleeding Disorder *

Yes

No

HIV / Hepatitis *

Yes

No

Epilepsy *

Yes

No

High / Low Blood Pressure

High

Low

N/A

Do you smoke (includes tobacco / vaping etc) *

Yes

No

How many each day?

Do you drink alcohol? *

Yes

No

How many each week?

Asthma *

Yes

No

Diabetes

Yes

Type I

Type II

No

FOR FEMALES: Are you pregnant?

Yes

No

Please list any other MEDICAL CONDITIONS you have?

Please list any MEDICATIONS you take (including prescription, over the counter, vitamins and herbal)

Please list any SURGERIES you have had:

Please list any ALLERGIES you have INCLUDING MEDICATIONS:

Do you take any BLOOD THINNING medications? (aspirin / warfarin etc) *

Yes

No

Have you ever taken any medicatons for osteoporosis/ bone density / bone cancer? *

Yes

No

Have you ever suffered excessive bleeding following a cut or surgical procedure? *

Yes

No

For anaesthetic purposes we require your weight

If 'YES': which medication?

For anaesthetic purposes we require your height

I declare that the info I’ve provided is accurate & complete

Your e-Signature (draw with mouse)

Thanks for submitting this medical history form.

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