Townsville Family Dental Practice in Kirwan

Dr Dinesh Singham
Dr Lindsay Smith
Dr. Joyce Hsu
Dr Ruth Smith
Dr Bethan John
Dr. Noy Gliksman

Patient Medical History

In order for us to provide the best possible service, we need to be aware of your medical history.

If you are a new patient, please fill in the form below with as much detail as possible. If you are not sure of any of the questions, or if your medical circumstances change, please inform your Dental Surgeon.

Title

Last Name

Given Names

Address

Post Code

Date of Birth

Occupation

Mobile Phone Number

Home/Work Phone Number

Email Address

Are you a Health Fund member?
Yes
No

Health Fund Details

If you are a member of a health fund, please fill in your details below

Health Fund Provider Name

Health Fund Number

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone Number

How did you hear about us?

Are you happy with the appearance of your teeth?
Yes
No

Medical History

All details will be strictly confidential

Past/Current medical conditions

Are you currently receiving any medical treatment?
Yes
No

If yes, please provide details

Have you had any serious or long standing illness?
Yes
No

If yes, please provide details

Have you ever been hospitalised?
Yes
No

If yes, please provide details

Do you have, or have you suffered from:

Rheumatic fever?
Yes
No
Any heart complaint/treatment?
Yes
No
Chronic Bronchitis or asthma?
Yes
No
Hepatitis / HIV?
Yes
No
Excessive bleeding?
Yes
No
Have you ever had brain surgery?
Yes
No
Joint replacements?
Yes
No
Diabetes?
Yes
No
Epilepsy?
Yes
No
Thyroid disorder?
Yes
No
High blood pressure?
Yes
No
Radiation/chemotherapy?
Yes
No

If you answered 'yes' to any of the above questions please suppy details here If you are not sure of any of the questions, or if your medical circumstances change, please inform the Dental Surgeon

Other Medical Information

Please inform us of any other conditions

Are you pregnant?
Yes
No

If yes, when is your due date?

Do you smoke?
Yes
No
Social
Do you wear sunscreen?
Yes
No
Occasionally
In the past 2 years have you undergone any operations?
Yes
No

If yes, please provide details

Are you allergic to any medicine or tablets?
Yes
No

If yes, please specify

Please list any medication taken in the last year