Please complete all fields. Name(Required) First Last Reg. No. (Office Use)(Required)Address(Required) . Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Sex(Required) M F Medical HistoryHeart Problem / Rheumatic fever / Jaundice / Epilepsy / Diabetes / BP(Required) Yes No Describe Heart Problem / Rheumatic fever / Jaundice / Epilepsy / Diabetes / BPAnaemia / Asthma / Allergies / Bleeding tendencies(Required) Yes No Describe Anaemia / Asthma / Allergies / Bleeding tendenciesFainting / Arthritis / Ulcer / Liver / Kidney / Thyroid(Required) Yes No Describe Fainting / Arthritis / Ulcer / Liver / Kidney / ThyroidTuberculosis / HIV / Hepatitis?(Required) Yes No Describe Tuberculosis / HIV / Hepatitis?Any other illnesses?(Required) Yes No Describe Any other illnesses?Any major medical problem/s in the past?(Required) Yes No Describe Any major medical problem/s in the past?Undergoing medical treatment at present?(Required) Yes No Describe Undergoing medical treatment at present?History of cancer in family?(Required) Yes No Describe History of cancer in family?Carrying a medical warning card?(Required) Yes No Describe Carrying a medical warning card?AllergiesLocal Anaesthesia?(Required) Yes No Describe Local Anaesthesia?Penicillin/medicines?(Required) Yes No Describe Penicillin/medicines?Substances/food?(Required) Yes No Describe Substances/food?Specific DetailsProlonged bleeding after injury?(Required) Yes No Describe Prolonged bleeding after injury?Blood Group?(Required) Taking medicines/pills currently?(Required) Yes No Describe Taking medicines/pills currently?Treatment History (5 Yrs)Cortisone / Steroids?(Required) Yes No Describe Cortisone / Steroids?Blood-thinning medication?(Required) Yes No Describe Blood-thinning medication?Antidepressants?(Required) Yes No Describe Antidepressants?Radiotherapy?(Required) Yes No Describe Radiotherapy?HabitsSmoke? (Amount per day?)(Required) Yes No Describe Smoke? (Amount per day?)Tobacco / Pan / Gutkha?(Required) Yes No Describe Tobacco / Pan / Gutkha?Visit dentist yearly? Last visit?(Required) Yes No Describe Visit dentist yearly? Last visit?Acidic drinks/foods?(Required) Yes No Describe Acidic drinks/foods?Acidic reflux?(Required) Yes No Describe Acidic reflux?Gums bleed?(Required) Yes No Describe Gums bleed?Bad breath/taste?(Required) Yes No Describe Bad breath/taste?Eating comfortably?(Required) Yes No Describe Eating comfortably?Floss / Interdental Brush?(Required) Yes No Describe Floss / Interdental Brush?Brush before sleep?(Required) Yes No Describe Brush before sleep?Toothpaste fluoride?(Required) Yes No Describe Toothpaste fluoride?Grind/clench teeth?(Required) Yes No Describe Grind/clench teeth?Snore at night?(Required) Yes No Describe Snore at night?Wake up with dry mouth?(Required) Yes No Describe Wake up with dry mouth?Headache in morning?(Required) Yes No Describe Headache in morning?What sport do you play? Covered by insurance? GeneralPregnant?(Required) Yes No Describe Pregnant?Happy with smile?(Required) Yes No Describe Happy with smile?Favourite music? Δ
