Medical History

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Thank you for choosing Moorooka Square Dental. To ensure we are looking after all your dental needs, we appreciate you taking the time to complete this confidential form.

PATIENT DETAILS

Give name *

Surname *

Date of birth *

Private Health Fund Name

Member Number

Address

Suburb

State

Post Code

Mobile *

E-mail *

Reason for the visit:

Are you in pain?

What is the nature of pain (please tick) throbbing dull ache sensitivity

Intensity of pain 1 to 10 : 1 2 3 4 5 6 7 8 9 10

Lingering (please tick) : seconds minutes hours constant on and off

Where in the mouth and face?

Are you concerned with the appearance of your smile?

Colour Shape Symmetry I don’t know and I’d like to find out

Are you interested in a comprehensive smile assessment to explore possibilities in aesthetic improvements?

How did you find out about us? *

Google Family/ friends Dentist Walked past Chat GPT, Gemini or AI Answers Other - please specify

Emergency / Under 18 legal guardian contact?

Emergency / Under 18 legal guardian contact number

Member Number

Individual reference number

GP details

Do you require prophylactic antibiotics?

Please tick any of the following that apply to you:

Any Heart Problems? * Yes No

(Pacemakers, valve replacements please note down year of placement.)

Excessive Bleeding? * Yes No

Medication related or blood disorder – please specify

Do you have high or low blood pressure? Is it controlled? * High – Controlled High – Uncontrolled Low – Controlled Low – Uncontrolled No issues

Diabetes?
Is this controlled? * Yes No

Rheumatic fever? * Yes No

Are you pregnant? * Yes No

Do you smoke? * Yes No

Any allergies to anaesthetics? * Yes No

Any allergies to penicillin / codeine? * Yes No

Any allergies to latex? * Yes No

Any other allergies please list

Any kidney or liver problems? * Yes No

Please specify

Cancer history? * Yes No

History of radiotherapy or chemotherapy? * Yes No

Please specify the year and region of the body

Osteoporosis? * Yes No

Are you currently taking medication?

HEP A/B/C or HIV? * Yes No

Any other health conditions?

List any medication you are currently taking:
If you have a long list please notify the front desk and send to info@moorookasquaredental.com.au for our records.

Please indicate if any of the following apply to you:

Do you snore regularly? Yes No

Do you wear any sleep appliances? Yes No

Do you often wake up unrefreshed? Yes No

Do you wake up with tension around your face, neck or back? Yes No

Consent for Treatment

• I understand that the use of anaesthetics involves risks. I can be informed of a recital of any possible complications.
• I am responsible for payment of all services rendered on my behalf and on behalf of my dependants. I understand that payment is due at the time of service. Moorooka Square Dental reserves the right to share and disclose personal information with a Credit reporting agency in the event of non-payment.
• We kindly ask that 24 hours notice is given before cancellations or rescheduling.
• To give you our full attention during your appointment, we may utilise secure AI tools to assist with our note-taking.

Would you like to receive oral care newsletters, special offers, and correspondence via email? Yes No

PAYMENT IS DUE AT THE TIME OF SERVICE. We have HICAPS facilities and accept all Visa, Mastercard, Eftpos, AfterPay, ZipPay and SuperCare & Cash.

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