Confidential Patient Questionnaire

This clinic is committed to protecting your privacy and this information is generally only disclosed to other members of your treating team where necessary.

Patient's name *
Patient's name
Name and number of your closest relative (next of kin)
Do you have private dental insurance?
Name and suburb
How do you like your tea/coffee?
Your dental history
Previous dental xrays were taken:
Have you ever seen a dental hygienist or a periodontist before?
Have you had any of the following?
Your medical history
Medical Doctor's name *
Medical Doctor's name
Are you currently being treated for a medical condition?
Have you had any serious medical problem in the past 5 years?
Do you have any long term or chronic medical problems?
Do you take regular medication or drugs, prescription or otherwise?
Do you have any heart condition?
Do you have, or have had, any of the following conditions?
Do you smoke?
Communicable diseases
In dentistry we deal with blood, saliva and tissues that can be infectious. We take every precaution and measure available to eliminate the risk of cross infection between patients and staff. In order to help provide you with optimum care please inform the dentist if you suffer from, or are at risk of contracting any of the following:
Please specify
Are you pregnant?
If yes what is the due date?
If yes what is the due date?
Declaration *
To the best of my knowledge I have answered these questions accurately and I will inform the dentist of any changes to my health status and/or medications in the future.