Medical Questionnaire Medical Questionnarie Step 1 of 3 33% PATIENT FAMILY DETAILS / CONFIDENTIALName* Address*Date of Birth Home Phone Business Phone Mobile Phone Email* RESPONSIBILE PARTY DETAILSThe Patient is a minor (under 18 years)* Yes No Living with Mother Yes No Mother's Name AddressHome Phone Business Phone Mobile Phone Email Living with Father Yes No Father's Name Father's AddressHome Phone Business Phone Mobile Phone Who is responsible for payment of accounts? Who can we thank for referring you to our practice? Who is your regular Dentist/Dental Nurse ? What is your school or place of work? MEDICAL HISTORY QUESTIONNAIREAre you being treated for anything now and if so what?Do you have any allergies? Do you carry a special health card or bracelet? Do you have any of the following problems? Heart problems?* Yes No Rheumatic Fever?* Yes No Diabetes?* Yes No Fits or Epilepsy?* Yes No Asthma?* Yes No Are you taking any medication for any of the above problems? If so please please list them here:Have you ever had any bleeding problems?* Yes No If yes, please give detailsHave you any reason to believe that you may be at risk of any infectious or other diseases? Yes No If yes, please give detailsThe medical history I have given is true and correct to the best of my knowledge* Yes
