Medical
history.

Type of private health insurance for dental treatment:

SmilenibHCFmedibank privateTUHMBF, HBA, Bupaveterans affairdefence healthothernone

Is there any reason for you to suspect that you may have AIDS, Hepatitis or are HIV positive?

yesno

Have you taken Aspirin, Warfarin, Pradaxa, Xarelto, Equilis or any other blood-thinning medications?

yesno

Have you ever taken any Bisphosonate medication – usually prescribed for osteoporosis (poor bone density), Paget’s disease and in some cancer treatments?

yesno

Have you ever been advised by a doctor or dentist (because of prior surgery, heart disease etc) that you require an antibiotic cover as a precautionary measure whenever you have routine dental treatment?

yesno

Please tick if you have any of the following:

rheumatic feverheart murmurepilepsydiabetesasthmacontact with HIV/AIDSprosthetic joints/vascular surgeryhaemophilia/prolonged bleedingheart condition/pacemaker/cardiac surgeryhigh blood pressure/any blood disorderkidney diseasehepatitis Ahepatitis Bhepatitis Ccancerallergy to aspirinallergy to penicillinallergy to latexany other allergies to drugs/food/medicine(ladies only) are you pregnant?

any other illness/disability

I have confidential information that I do not wish to write down. I would prefer to speak to the Dentist about this.

I have completed this form to the best of my knowledge and on future visits will advise the Dentist of any changes to the history.