Healthy Smiles Australia - www.healthysmile.com.au

150 Canterbury rd,
Blackburn South VIC 3130
ph: 03 9877 2035 | fax: 03 9877 2035

Cosmetic Dentistry

General Treatments

Medical History Questionnaire

Request an appointment

Medical History Questionnaire

Full Name

Address

Home Phone

Work Phone

Mobile Phone

Date of Birth

Health Insurance

Who referred you to our office?:

When was your last dental visit?

What has been your concern with previous dental visits?

Are you being treated for a medical condition?

Who is your doctor?

Are you taking any medications or supplements at present, both prescribed or over the counter? (Please List)

Do you have, or have you ever had, any of the following medical conditions?
(Hold down Ctl & click to pick multiple conditions)

Please list all known allergies

Do you smoke? * Yes No

For females, are you pregnant or undergoing fertility treatment? * Yes No

Ph: 03 9878 6657 • Fax: 03 9877 2035
150 Canterbury Road, Blackburn South VIC 3130