Title* Mr Mrs Miss Ms

First Name*

Family Name*

Preferred Name*

Date of Birth*

Address*

Suburb*

Postcode*

Phone Home*

Phone Work

Mobile

Email*

Private Health Insurance Company

None

Who is your General Dentist

Unknown

How did you hear about us? / Referred by?*

Have we treated another member of your family?*

What are the main concerns that you would like orthodontics to accomplish?*

Have you visited an orthodontist before* Yes No

Name of previous Orthodontist*

Are you receiving any medical treatment

Are you currently taking any medications

History of major illness?

Have there been injuries to your face, mouth or chin

Have you ever had pain/ tenderness in your jaw joint (TMJ/TMD)?

Do/Did you have any of the following habits?

Grinding Teeth

Chronic Mouth Breathing

Chewing/Eating Problems

Finger/Thumb Sucking

Tongue Thrusting

Speech Problems

Responsible for Account Yes No

Title* Mr Mrs Miss Ms

First Name*

Family Name*

Address*

Suburb

Postcode

Phone Home*

Phone Work

Mobile

Email*

Private Health Insurance Company

None

In signing this form I acknowledge that this represents an accurate medical history. I will also supply my dentist with any relevant changes to this history as required. All medical information will be treated with complete professional confidentiality within the guidelines of the Privacy Act 12/01 and through the obligations health service providers have under the Professional and Ethical Codes of Practice.

Date*

Adult Medical History Form

Patient Information Form ADULT (≥18 years)

Dental & Medical History

Account Responsibility

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