Medical history questionnaire

Dental Record Number (DRN) *Please refer to our correspondence for the DRN details

INSTRUCTIONS

1. It is assumed that the patient is completing this form.  If you are completing this form on behalf of the patient please read all references to "You" as referring to the patient in question.

2. This form has multiple sections that need to be filled in. Please r

   eview and answer all relevant sections and questions and u

   se free text boxes for details and additional information. 

3. If uncertain about any of the questions or requiring assistance, please discuss with your carer, medical doctor, or dental clinician 

4. If you have multiple medical conditions, medications or have a complex medical status; please obtain a medical history and medications list from y our attending doctor or specialist. 

5. A New Medical history questionnaire is required for every new course of care, annually or when there is a significant change. 

6. Medical History Questionnaire will be checked and confirmed at every visit, so please update your dental clinician if any changes.

I understand that if I am not able to complete this medical history I will need to provide a medical history prior to the dental appointment or it will delay the appointment or any treatment necessary. Please see your GP or medical specialist to get a printed copy of your medical history. *

I have reviewed and understand my Rights and Responsibilities as outlined on the DHSV website *

Your Profile (The Patient)

Title *

First Name *

Last Name *

Date of Birth *NOTE - confirm day, month and year are correct.

Telephone

Mobile

e-mail address

Address *

Do you identify as Aboriginal or torres straits islander?

YesNoPrefer not to say

You (the patient) can give self consent to the treatment and care? *

YesNoUncertain

Please specify person who can give consent (parental responsibility or medical treatment decision maker) *

Next of kin/family/carer whom we can contact if necessary

Who is filling in this medical history questionnaire? *

myself (the patient)parent or family memberpatient with the assistance of the treating dental clinicianother

 Full name, relationship, (clinician code if applicable)

Name and contact details (address/phone number) of main dental practitioner ( if not in RDHM)

Name and contact details (address/phone number) of main medical practitioner (GP)

Name and contact details of any additional medical practitioner or specialist involved in your care in the last 5 years.

Are you currently linked in with external support service or support worker *

YesNoUncertain

Please provide details *

Are you able to provide a Medical history from your medical practitioner to bring to next appointment. *

YesNoUncertain

Scanned Medical History

Browse

Please upload a scanned copy of the medical history in the following file format. pdf, jpg, jpeg, docx, doc, png

Do you consent to provding access to MyHealthRecords.

YesNo

Medical History Questions

Patient Height (cm) *

Patient Weight (kg) *

BMI

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Are you at risk of falling down, or have you had a fall in the last 28 days? *

YesNoUncertain

instability when walking or moving

please specify *

Currently pregnant or breastfeeding? *

YesNoUncertain

Have you had a splenectomy? (removal of entire spleen) *

YesNoUncertain

Are you currently undergoing, or have previously undergone head and neck Radiotherapy treatment? *

YesNoUncertain

Are you currenlty undergoing or have previously undergone Chemotherapy or other cancer treatment? *

YesNoUncertain

if you have answered yes to any question above, please provide further details *

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Have you had previous complications receiving dental treatment? *

YesNoUncertain

Please specify *

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Are your immunizations up to date? (especially for children) *

YesNoUncertain

Have you had HPV (Human Papilloma Virus) Vaccine? *

YesNoUncertain

Do you have any additional or special needs or require additional assistance/support in any way? *

YesNoNot Applicable

Specify *

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(for children), Any exposure in the last 3 weeks, or currently have measles, chicken pox, rheumatic fever, or any other infectious disease.

YesNoNot Applicable

Specify *

Cardiovascular & Respiratory

Do you have any current, ongoing or previous medical conditions or concerns in the following areas? (Cardiovascular & Respiratory)

• Congenital heart disease

• Blood pressure

• Heart failure

• Irregular heartbeat/ Heart murmur

• Chest pains/ angina

• myocardial infarction

• Heart valve problems/ Heart valve replacement

• Circulation issues/ Swelling of ankles

• Previous Endocarditis

• pacemaker

• shortness of breath

• emphysema / COAD

• wheeze/chronic bronchitis/asthma

• pneumonia

• Sleep apnoea / Using CPAP/ snoring or stops breathing during sleep.

• lung problems needing hospital attendance

• Other

Select all that apply *

Congenital heart diseaseBlood pressureHeart failureIrregular heartbeat/ Heart murmurChest pains/ anginamyocardial infarctionHeart valve problems/ Heart valve replacementCirculation issues/ Swelling of anklesPrevious Endocarditispacemakershortness of breathemphysema / COADwheeze/chronic bronchitis/asthmapneumoniaSleep apnoea / Using CPAP/ snoring or stops breathing during sleep.lung problems needing hospital attendanceOther

Cardiovascular AND Respiratory *

YesNo

If you answered "Yes" to any of the above, please provide further details *

Endocrine, Hepatic and haematological

Do you have any current, ongoing or previous medical conditions or concerns in the following areas? (Endocrine, Hepatic and haematological)

• Thyroid

• Diabetes

• Other Metabolic

• Abnormal liver function

• Jaundice

• Hepatitis

• Cirrhosis

• Liver failure

• Bruising/ Excessive bleeding in self or family member

• blood clots or bleeding disorders with self or family member

• Anaemia

• Previous blood transfusions

• HIV/AIDS or other blood-borne diseases

• Other
  

Select all that apply *

ThyroidDiabetesOther MetabolicAbnormal liver functionJaundiceHepatitisCirrhosisLiver failureBruising/ Excessive bleeding in self or family memberblood clots or bleeding disorders with self or family memberAnaemiaPrevious blood transfusionsHIV/AIDS or other blood-borne diseasesOther

Endocrine, Hepatic and haematological *

YesNo

If you answered "Yes" to any of the above, please provide further details *

Musculoskeletal & Nervous systems

Do you have any current, ongoing or previous medical conditions or concerns in the following areas? (Musculoskeletal and  Nervous systems)

• Osteoarthritis

• Rheumatoid arthritis

• Backaches/sciatica

• Neck problems

• difficulty opening mouth

• Muscle related illnesses

• Joint problems

• Artificial prosthesis

• chronic pain

• MigrainesDizziness

• Leg or arm weakness

• Stroke

• seizures/epilepsy/fits/Febrile convulsions

• delirium, blackouts or fainting

• other

Select all that apply *

OsteoarthritisRheumatoid arthritisBackaches/sciaticaNeck problemsdifficulty opening mouthMuscle related illnessesJoint problemsArtificial prosthesischronic painMigrainesDizzinessLeg or arm weaknessStrokeseizures/epilepsy/fits/Febrile convulsionsdelirium, blackouts or faintingother

Musculoskeletal and  Nervous systems *

YesNo

If you answered "Yes" to any of the above, please provide further details *

Gastrointestinal & genitoUrinary

Do you have any current, ongoing or previous medical conditions or concerns in the following areas? (Gastrointestinal & genitoUrinary)

• Irritable bowel, Coeliac disease,Ulcerative colitis, Crohn’s disease

• Nausea/vomiting/appetite loss

• Indigestion/Heartburn/reflux/hiatus hernia

• gastric ulcers

• Kidney/bladder infections

• On dialysis

• Kidney Transplants

• other

Select all that apply *

Irritable bowel, Coeliac disease, Ulcerative colitis, Crohn’s diseaseNausea/vomiting/appetite lossIndigestion/Heartburn/reflux/hiatus hernia/gastric ulcersKidney/bladder infectionsOn dialysisKidney Transplantsother

Gastrointestinal and genitoUrinary *

YesNo

If you answered "Yes" to any of the above, please provide further details

Sensory, cognitive, neuropsychiatric & other

Do you have any current, ongoing or previous medical conditions or concerns in the following areas? (Sensory, cognitive, neuropsychiatric, and other)

• Sensory 

• Intellectual impairment

• Difficulty communicating 

• Physical impairment

• Cerebral palsy

• Downs syndrome

• Dementia

• Schizophrenia  / psychosis

• Depression

• Panic attack and anxiety

• Attention deficit disorders

• Intellectual and cognitive impairment

• Autism spectrum disorder

• Other
  

Select all that apply *

SensoryIntellectual impairmentDifficulty communicatingPhysical impairmentCerebral palsyDowns syndromeDementiaSchizophrenia  / psychosisDepressionPanic attack and anxietyAttention deficit disorders​Intellectual and cognitive impairmentAutism spectrum disorderOther

Sensory (Please select) *

SightHearingTasteTouchSmell

Intellectual impairment (Please select) *

LearningBehavioural

Difficulty Communicating (Please select) *

VerbalNon-VerbalAuslanLip Reader

Sensory, cognitive, neuropsychiatric, and other *

YesNo

If you answered "Yes" to any of the above, please provide further details *

 ​Other not previously mentioned or included.

Any other condition that is not mentioned? *

YesNouncertain

eg poor teeth, recent prednisolone, other transplants

Other Conditions *

Any other condition that runs in the family? *

YesNouncertain

eg thalassemia, muscular dystrophy

Specify family condition(s) *

Allergies & adverse drug reactions

Do you have any of the following allergies or adverse drug reactions? (Allergies and adverse drug reactions)

• Medications – antibiotics

• Medications - anaesthetics

• Other medications

• Latex/rubber products/gloves

• Tapes

• Antiseptics

• Food

• Other substances

• Blood relatives with relevant allergies or adverse drug reactions of interest
  

Select all that apply *

Medications – antibioticsMedications - anaestheticsOther medicationsLatex/rubber products/glovesTapesAntisepticsFoodOther substancesBlood relatives with relevant allergies or adverse drug reactions of interest

Allergies and adverse drug reactions *

YesNo

Specify details of reaction for EACH selection above *

Medications

List any medication that you are currently taking? (including medications if they may be of dental interest / concern)

Medication (1)

Routeorally ( by mouth)injection - IV or  IM or SC or intrathecalsublingual or buccal ( under tongue or cheek )rectal or vaginalocular or otic ( via the eye or ear)nasal ( through the nose)inhalation or nebulization ( through breathing in)cutaneous or topical or transdermal ( on the skin)

Frequency. dose, duration , reason

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Medication (2)

Routeorally ( by mouth)injection - IV or  IM or SC or intrathecalsublingual or buccal ( under tongue or cheek )rectal or vaginalocular or otic ( via the eye or ear)nasal ( through the nose)inhalation or nebulization ( through breathing in)cutaneous or topical or transdermal ( on the skin)

Frequency. dose, duration , reason

---

Medication (3)

Routeorally ( by mouth)injection - IV or  IM or SC or intrathecalsublingual or buccal ( under tongue or cheek )rectal or vaginalocular or otic ( via the eye or ear)nasal ( through the nose)inhalation or nebulization ( through breathing in)cutaneous or topical or transdermal ( on the skin)

Frequency. dose, duration , reason

---

Medication (4)

Routeorally ( by mouth)injection - IV or  IM or SC or intrathecalsublingual or buccal ( under tongue or cheek )rectal or vaginalocular or otic ( via the eye or ear)nasal ( through the nose)inhalation or nebulization ( through breathing in)cutaneous or topical or transdermal ( on the skin)

Frequency. dose, duration , reason

---

Medication (5)

Routeorally ( by mouth)injection - IV or  IM or SC or intrathecalsublingual or buccal ( under tongue or cheek )rectal or vaginalocular or otic ( via the eye or ear)nasal ( through the nose)inhalation or nebulization ( through breathing in)cutaneous or topical or transdermal ( on the skin)

Frequency. dose, duration , reason

---

List other Medication(s) including vitamins, herbal remedies, over the counterIf you have a complex medications list, please obtain a copy from your GP or pharmacist.

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Do you take anticoagulants and /or antiplatelets? *

YesNoUncertain

Do you take Corticosteroids/Steroids? *

YesNoUncertain

Do you take, or have taken Bisphosphonates and/or other anti-resorptive injections or medications? *

YesNoUncertain

Have you previously, or currently require prophylactic antibiotics (antibiotics taken before dental treatment)? *

YesNoUncertain

Provide further information on the "Yes" answer(s) above *

Social & Lifestyle

Do you smoke?

YesNeverI have given up

How many years have you been smoking? *

How many cigarettes do you smoke on a typical day? *31 or more21-3011-2010 or less

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Do you chew tobacco or betel nut?

YesNeverI have given up

also known as areca nut, paan, supari, bin lang, puwak

How many years have you been chewing tobacco or betel nut? *

How many times a week do you chew tobacco or betel nut? *Every day4-5 days a week1-3 days a week

How much do you use daily? *1-9 pieces10-19 pieces20-29 pieces30-99 pieces100 more pieces

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Do you drink alcohol?

YesNeverI have given up

For how many years have you drunk alcohol? *

How often per week do you have a drink containing alcohol? (per week) *4 or more times2 to 3 timesless than once

How many alcoholic drinks do you have on a typical day? *10 or more7 to 95 to 63 to 41 to 2

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Living situation (if patient is an adult 18+)HouseFlatRetirement villageNursing homeResidential CareHomelessOtherPrefer not to say

Or

Living situation (if patient is a child)ParentsGrandparentsExtended familyFoster careChild ProtectionOtherPrefer not to say

Specify *

Do you liveAloneWith immediate familyFriends or extended familyIn careOtherPrefer not to say

Other housing issues

Social isolationStressful home environmentHousing stressPoor access to transportOtherPrefer not to say

Discrimination

ReligiousRacialGenderSexual orientationGender identitySocial isolation or exclusionOtherPrefer not to say

Other stressors

PovertyLow incomeWorking conditionsInsecure employmentWork stressUnpaid carerPersonal debtOtherPrefer not to say

Legal / Justice

Current incarcerationCurrent legal proceedingsPrevious contact with the justice systemOther Legal / Justice issuesPrefer not to say

Substance abuse & addictions

AlcoholPrescription drugsNon-prescription medications (eg OTC cough and cold medication)Illicit substances, ice( crystal meth)GamblingInternet/social media

Do any of your family / friends battle with an addiction issue(s)?

YesNoPrefer not to say

Specify *

Trauma experience

TortureSexual assaultChild abuse or neglectElder abuse or neglectWar or armed conflictCrime victimOther forms of violence or abusePrefer not to say

General Anesthesia & Dental Surgical Unit

Are you booked or planning to have a general anesthetic or surgical procedure in the next 6 months? *

YesNo

Have you been hospitalized for any health problems including previous surgery or general anesthesia? *YesNoUncertain

Reason for hospitalisation and when *

Have you had any complications with previous treatment, surgery or General anaesthesia? *YesNoUncertain

Provide details of complication *

Have you had any close relatives with complications or problems with general anaesthesia? *YesNoUncertain

Please specify *

(If the patient is a child) were they born prematurely?

YesNoUncertain

Please indicate how far you can walk without stopping AND no chest pain or shortness of breath? ( a flight of steps is approximately 6 steps) *more than 2 flights2 flights1 flighthalf a flightaround the house

Do you have, Rashes, Pressure ulcers, wounds, dressings *YesNoUncertain

Please specify *

Do yo have mobility issues? *YesNoUncertain

Please specify *

Select any mobility aids *

WheelchairAssistance of carerMobility scooterAmbulance transportOther

Do you have the ability to walk without stopping? *YesNoUncertain

Please specify *

Do you have breathing issues? *YesNoUncertain

Please specify *

Any additional information that could be relevant? *

YesNo

Specify *

Do you have a "not for recescitation order" in place? *

YesNo

Please upload a copy of the order *

Browse

Please upload a document in the following file format: pdf, jpg, jpeg, docx, doc, png

Has a doctor ordered medical tests or examinations in the last year? *

YesNo

Please provide Doctor name, address, and contact number. *We may seek a copy of your medical history from the doctor above. Please instruct your doctor that you consent for the release of your medical history to DHSV.

Patient consent

The authorised entity to sign

Patient, parent, guardian, medical treatment decision maker

I confirm that the answers that I have provided to be correct. If under 18 years of age, then parent or guardian to sign. *

Draw signature|Type signatureClear

Signatory - Mobile number *

Send code

Submit code

Resend code

By validating this mobile number, we are confirming the identity of the authorised entity providing consent.

 

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