New Patient Form Date * MM DD YYYY Patient Details * First Name Last Name Title * Mr Mrs Ms Master Miss Dr Other Middle name Preferred name (what do you like to be called?) Date of birth * MM DD YYYY Gender * Male Female Unspecified Mobile number (###) ### #### Home number (###) ### #### Work number (###) ### #### Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medicare and Health Funds Do you have a Medicare card? Yes No Medicare card number 10 digits long Medicare Reference Number The number beside your name on your card. Medicare Expiry Date MM/YY Do you have private health insurance / extras / Hospital cover? * Hospital and extras Hospital only Extras Only Not sure No Health Fund Name Health Fund Membership Number Health Fund Reference Number eg: 00, 1, 2 A small number besides your name on the card Occupation Place of work Dental Practitioner First Name Last Name Address or Suburb Medical Practitioner First Name Last Name Address or Suburb Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship of emergency contact * Health Questionnaire 1. Are you currently receiving medical treatment? Yes No 2. Have you ever been admitted to hospital? Yes No If yes, please provide details: 3. Do you or have you ever had any of the following? Alcohol Abuse Anaemia Arthritis Asthma / Bronchitis Bleeding Disorders Cancer Cold Sores Depression Diabetes (type 1 / type 2 / gestational) Drug Dependence Epilepsy Gastric Problems Heart Trouble Hepatitis A, B or C High Blood Pressure HIV / AIDS Kidney Trouble Mental Illness Migraine Headaches Osteoporosis or other bone disease Other respiratory or lung disease Rheumatic Fever Stroke or TIA Tuberculosis Other If other, please provide details: 4. Are you taking any medications? * Including over the counter pills & tablets. Yes No If yes, please provide details of which medications, pills or tablets you are taking: 5. Are you allergic to any medication? * Including over the counter pills & tablets. Yes No If yes, what medications are you allergic to? 6. Have you had joint replacement surgery? * e.g. prosthetic knee, hip Yes No 7. Have you had any other surgery? * Yes No 8. Have you ever experienced excessive bleeding or bruising from cuts, scratches or surgery? * Yes No 9. Have you ever had contact with the hepatitis or AIDS/HIV virus? * Yes No 10. Have you ever had a reaction to an anaesthetic? * Yes No 12. Can you easily walk up two flights of stairs without stopping? * Yes No 13. Do you smoke? * Yes No 14. Do you drink alcohol? * Yes No 15. Any family history of cancer? * Yes No Is there anything else regarding your health that you think we should know about? Other Information How would you prefer your treatment to be performed (you can select more than one option)? Local anaesthesia (fully awake in the dental chair) Green whistle Intravenous sedation / twilight sleep (very drowsy and groggy in the dental chair) General anaesthesia (fully unconscious in hospital) No preference / Don't know / Whatever the surgeon thinks is best Declaration & Signature The medical history I have given is true and correct to the best of my knowledge. I have disclosed all medications including over-the-counter and herbal remedies that I am taking. I give permission for a copy of this online form to be sent via email to AWOMS. I give permission for a copy of correspondence letters and test results to be sent to the GP I have indicated on this form. Thank you!
