Health History Form - Sara Couch & Associates

Personal Details

Name

Title Family Name Given Name Preferred Name

Date of birth

dd/mm/yyyy

Address

Street Address Address Line 2 City ZIP / Postal Code

Home Number

Work Number

Mobile Number

Email*

Family Doctor

Family Doctor phone number

Family Doctor Address

Street Address City ZIP / Postal Code

Private Health Fund

DVA no.

Medical History

Have you ever had any of the following?

please tick all that are relevant

If yes, your due date

Bisphosphonate Medications

Bisphosphonate drugs are typically used in the prevention of osteoporosis or in the management of cancer. Common brand name drugs containing bisphosphonates include:

Orally: Actonel, Alendro, Bonefos, Bonviva, Didrical, Didronel, Fosamax, Skelid

Injection: Aclasta, Aredia, Pamisol, Zometa

Do you take or have you ever taken (by prescription or administration) any bisphosphonate drugs?

Yes
No

Please list any medications you take regularly (other than above):

Oral Health Questions

Do you experience sensitivity with hot/cold?

Yes
No

Does floss ever tear between your teeth?

Yes
No

Do your gums ever bleed when you brush your teeth?

Yes
No

Do your teeth ever hurt when you bite hard?

Yes
No

Does food get jammed between your teeth?

Yes
No

Have you ever had orthodontic treatment?

Yes
No

Do you think you have occasional bad breath?

Yes
No

Does your jaw click or hurt?

Yes
No

Have you ever had gum disease?

Yes
No

Do you grind your teeth?

Yes
No

Do you smoke?

Yes
No

Do you wear a night guard?

Yes
No

What is the main purpose of this visit?

How long since your last dental appointment?

How often do you usually have dental examinations?

Previous dental x-rays were taken

Less than a year ago
More than a year ago

Is another member of your family a patient of our practice?

Yes
No

How did you find us?

(Please tick)

Signature

Today's Date

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