top of page

Patient Medical History Form

Please fill out the following form for your upcoming appointment.

Personal Details

Insurance Details

Do you have PRIVATE HEALTH Insurance?
Do you have hospital cover?
Do you have EXTRAS COVER?
Do you have coverage under VETERANS AFFAIRS (DVA) ?
GOLD / WHITE Card Holder
Are You Covered Under Workers Compensation for this Treatment?

Medical Details

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

Have you been diagnosed with any of the following conditions?

Heart Disease / Surgery
Cancer
Have you ever had any of the following treatments?
Heart Attack
Stroke
Bleeding Disorder
HIV / Hepatitis
Epilepsy
High / Low Blood Pressure
Do you smoke (includes tobacco / vaping etc)
Do you drink alcohol?
Asthma
Diabetes
FOR FEMALES: Are you pregnant?
Do you take any BLOOD THINNING medications? (aspirin / warfarin etc)
Have you ever taken any medicatons for osteoporosis/ bone density / bone cancer?
Have you ever suffered excessive bleeding following a cut or surgical procedure?

Thanks for submitting this medical history form.

bottom of page