Patient Questionnaire Title*MissMrsMrDrOtherFirst Name(s)* Last Name* Address* Suburb Phone (Home) Phone (Mobile)* DOB* Occupation Work Address* Suburb Phone (Work) Emergency Contact PersonName* Contact Number* Medical HistoryMedical Doctor Contact Number Past Dentist Date of last visit MM slash DD slash YYYY ￼￼￼￼￼￼￼￼￼Do you have a history of any of the following conditions? (Tick all that apply) Arthritis Bleeding problems/Anaemia Chest problems/COPD/Asthma Cold sores Despression Diabetes Epilepsy/Fits/Fainting Gastric problems/kidney problems Heart problems Hepatitis A Hepatitis B Hepatitis C Hepatitis D High blood pressure Osteoporosis Rheumatic fever Drug/alcohol dependence Please specify yes to any of the following: Do you have any food, drug or other allergies? Have you been hospitalised in the past two years? Have you had any prosthetic surgery? (e.g. heart valve, stent, joint replacement, pacemaker etc.) Female only: Are you pregnant? Are you HIV positive? Have you taken any medicine, tablets, capsules or drugs in the past two years? If currently taking, please list Are you currently taking warfarin or fosamax? Please write details hereHow did you hear about us? Please tick all that apply Yellow Pages Street Sign Website Word of mouth Other (please specify) CommentsThis field is for validation purposes and should be left unchanged.