The Periodontists Confidential Questionnaire

Title:

Surname:

First Name:

Date of Birth:

Preferred Name:

Address:

Occupation:

Home Ph:

Mobile Ph:

Work Ph:

Email:

Department of Veterans Affairs (DVA) Member No.:

Health Fund & Member No.:

Medicare No.:

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?

Please List:

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

Any Operations/illnesses Not Listed?

Do You Vape/Smoke, if So How Often/Many Per Day?

Do you Have a Previous History of Vaping/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?

If ‘Internet: Other’, which search engine?

If ‘Existing Patient’ or ‘Not a Patient’, Who Recommended You?

Patient:

Parent / Responsible Party’s signature:

Date:

Relationship to Patient:
SelfMotherFatherSiblingCarerOther

Any Relevant Files: