Medical History Form

If you are a new patient to Glebe Dental, we warmly welcome you to our practice and look forward to providing you with exceptional care.

As a new patient you will be asked to complete a medical history form. This will help us determine your current oral and general health, make our team aware of any medication you may be taking as well as any procedures you have had previously.

It is important you provide as much information as possible. If you are unsure of anything, please don’t hesitate to ask one of our friendly team members.

Patient Information

Surname: *

Given Name: *

Preferred Name: *

Title:

Address:

Subrb:

Postal Code:

Home Phone:

Work Phone:

Fax/ Mobile Number:

Please tick preferred contact method:

 Email Home Phone Work Phone Mobile SMS

Email Address: *

Date of Birth: *

Health Fund:

Occcupation:

Billing Address:

How did you hear about our Practice?

Person's Name:

If non-referred please tick:

 Google, please specify words searched

 Internet Yellow Pages Yellow Pages Phone Book Flyer Saw Sign Website Facebook Radio
 TV,please specify
 Other, please specify


DENTAL HISTORY

Have you suffered recently from the following dental problems? Please tick

Sensitivity to hot or cold or when eating  

 Yes No

Food trapping between teeth  

 Yes No

Clicking or pain in the joints of the jaw  

 Yes No

Roughness of your teeth or fillings  

 Yes No

Bleeding gums  

 Yes No

Bad taste or bad breath  

 Yes No

Jaw clenching or grinding  

 Yes No

Head Neck ache  

 Yes No

Has fear or anxiety ever been a factor in getting your dental work done?  

 Yes No

What is the purpose of your visit?

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