The Periodontists Confidential Questionnaire Want an appointment? Want an appointment? Book Today Fill Out the Form Below or Download the PDF Download Form Title: Surname: First Name: Date of Birth: Preferred Name: Address: Occupation: Home Ph: Mobile Ph: Work Ph: Email: APPOINTMENT Reminders? EMAILSMS Emergency Contact & Relationship: Emergency Contact Ph: Your Dr/Medical GP: Dr/Medical GP Ph: Department of Veterans Affairs (DVA) Member No.: Health Fund & Member No.: Medicare No.: Do any of the following apply to you? (Tick Yes) Do Your Gums Bleed When You Brush or Floss Your Teeth?Do You Have a Bad Taste in Your Mouth or Bad Breath?Do You Have Any Missing Teeth You Would Like to Replace?Do You Have Any Gaps in Your Teeth Which Catch Food?Do You Feel Nervous/anxious About Dental Treatment?Have You Noticed Any Lumps/bumps/ulcers in Your Mouth?Do You Think You Grind Your Teeth?Does Your Jaw Click or Hurt?Do You Experience Any Gum Pain?Do You Have Any Loose Teeth?Do You Have Any Gum Recession/shrinkage?Do You Experience Sensitivity With Hot/cold?Would You Prefer to Have Your Periodontal Treatment With Intravenous Sedation or a General Anesthetic? Previous Dental History Who Is Your General Dentist? If not your general dentist, who referred you to Dr Samy Francis? How long since your last general dental appointment? Have you had periodontal treatment before? Are you happy for you & your dental/medical professionals to receive correspondence by email from The Periodontists? YesNo What concerns do you have about dental treatment? FearCostPainTime ConstraintsOther Please List: Medication and Recreational Drug Specifics & History To ensure we provide the best possible care, please complete the following: DO YOU or HAVE YOU EVER Taken Medications for Osteoporosis and/or Chemotherapy? (If Yes, Please Specify in the Table Above) YesNo MEDICATION DECLARATION: In signing this form I acknowledge this represents an accurate medication history. I will advise my dentist of any changes to my medical history in the future. I understand all medical details will be treated with complete professional confidentiality. I have read The Periodontists privacy policy document Patient: Parent / Responsible Party’s signature: Date: Relationship to Patient: SelfMotherFatherSiblingCarerOther SEE ‘MEDICAL QUESTIONNAIRE’ BELOW, IF YOU’RE AN EXISTING PATIENT AND HAVE HAD NO CHANGES PLEASE TICK HERE:No Changes Have you had or have any of the following, please indicate appropriately? (Tick Yes) Allergies to Medications Anaemia or Other Blood Clotting Disorders Anaesthetic Sensitivity GA / LA / IV Antibiotic Required Prior to Dental Treatment Anxiety / Depression Asthma / Bronchitis / Lung Conditions Blood Pressure HIGH / LOW Cancer Diabetes Diabetes – Family History Epilepsy / Neurological Conditions Excessive Bleeding Excessive Bruising Heart Problems Heart Valve Replacement Hepatitis A / B / C HIV/AIDS Joint Replacement Surgery Liver or Kidney Problems Neck, Jaw or Shoulder Damage/pain Osteoporosis Rheumatic Fever Sinus Trouble Stomach Ulcers Are You Pregnant or Breastfeeding Any Operations/illnesses Not Listed? Do You Smoke, if So How Many Per Day? Do you Have a Previous History of Smoking? YesNo Approx Date Quit? Do You Drink Alcohol, if So How Many Units Per Day? Is There Anything Else We Have Not Covered Please Advise? TO BE COMPLETED BY NEW PATIENTS ONLY How Did You Hear About Us? Yellow Pages: BookYellow Pages: OnlineInternet: GoogleInternet: OtherNot a PatientDentist/specialistWalk/drive PastThe Periodontists WebsiteExisting Patient If ‘Internet: Other’, which search engine? If ‘Existing Patient’ or ‘Not a Patient’, Who Recommended You? CONFIDENTIAL QUESTIONNAIRE DECLARATION: In signing this form I acknowledge this represents an accurate medical history. I will advise my dentist of any changes to my medical history in the future. I understand all medical details will be treated with complete professional confidentiality. I have read The Periodontists privacy policy document. Patient: Parent / Responsible Party’s signature: Date: Relationship to Patient: SelfMotherFatherSiblingCarerOther Any Relevant Files: Download PDF View Form
