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Patient Questionnaire Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Your Health Information - Privacy Consent Form

Our practice respects your right to privacy and it has systems and processes in place to ensure it complies with the Australian Privacy Principles (APPs). The practice privacy policy is available on request.
Our practice Smile In Style ABN 84 930 850 453 collects information about you for the purpose of providing health services to you. In addition, personal information such as your name, address and health insurance details are used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our services and any issues affecting your health care. We may collect information about you from third parties providing the collection of that information is necessary to provide you with health care.
We may disclose your health information to other health care professionals, or require it from them if, in our judgement, it is necessary in the context of your care.
We may also use parts of your health information for research purposes, in study groups or at seminars; however, in such situations, your personal identity will not be disclosed without your consent.
If you choose not to provide us with information relevant to your care, we may not be able to provide a service to you, or the service we are asked to provide may not be appropriate for your needs. Importantly, if you do not provide information that may be relevant to your care or that is otherwise requested by us, you could suffer some harm or other adverse outcome.
Your medical history, treatment records, x-rays and any other material relevant to your care will be stored by the practice. The practice privacy policy sets out how you can access your records or seek correction of your records.
The practice privacy policy sets out how you may complain about a breach of privacy and how the practice will deal with such a complaint.
As part of its electronic records system, the practice may rely on cloud storage providers located outside Australia. The practice will ensure that any offshore transfer complies with its obligations under the APPs.
The practice Privacy Officer can be contacted at the practice during business hours if you have any concerns or questions about a privacy matter.
Please sign this form below, as confirmation that you have read and understood the above information and consent to the collection and use of your health information.

Patient Information

Title : Prof Dr Fr Mr Mrs Ms Miss Master
Patient Name :
*Last Name :
Middle Name : *First Name :
*Date of Birth :
*Home Address
City :
State :
Postcode :
*Home Phone # :
Mobile Phone # :
Work Phone # :
*Email Address :
Occupation :
Health Insurance :
Member ID # :
Contact person in case of emergency :
Phone/Mobile # :
Person responsible for dental account?
*Who referred you to our office?
Would you like to subscribe to our newsletter? Yes No
When was your last dental visit?
What has been your concern with previous dental visits?
What is your main dental concern today?
Are your teeth sensitive to : Heat Cold Sweet Biting Pressure
dental visits: Preferred practice for appointments : Moonee Ponds Sunbury
Does food catch between your teeth? Yes No
Do your gums bleed when brushing or flossing? Yes No
Do you notice an unpleasant taste or odour in your mouth? Yes No
Have you had any complications during or following dental treatment? Yes No
If Yes, Explain :
Have you had prolonged bleeding after tooth removal or dental surgery? Yes No
Are you happy with the appearance of your teeth/gums/smile? Yes No
If no, What don’t you like about your smile?
Would you like to discuss enhancing the appearance of your smile? Yes No
Would you like to discuss how to make your teeth WHITE? Yes No
Do you grind your teeth or clench your jaws? Yes No
Have your jaw muscles ever been sore? Yes No
Do you snore at night? Yes No
Do you suffer from daytime sleepiness? Yes No
Please describe how you feel about dental treatment by clicking on the dotted line :
Terrible Pleasant
Are you being treated for a medical condition? Yes No
If Yes, Explain :
Medical Doctor:
Doctor’s Address :
City :
State :
Postcode :
Phone Number :
Are you taking any medications or supplements at present, both prescribed or over the counter? (Please list)
Are you taking any bisphosphonate medication or any other medication to treat osteoporosis?
Do you have, or have you ever had, any of the following medical conditions?
Steroid therapy
Rheumatic fever
Epilepsy
Asthma
Diabetes
Heart valve disorder
Stroke
Heart murmur
Kidney disease
Tuberculosis
Eating disorder
Leukaemia, cancer
Nervous condition
Heart complaint or heart surgery
Thyroid disease
Radiation or chemo therapy
High blood pressure
Low blood pressure
Stomach or digestive condition e.g. reflux
Transplanted organ or bone marrow
Cardiac pacemaker
Excess bleeding
Hepatitis or liver disease
Contact with HIV/AIDS virus
Anaemia or Blood Disorder
Prosthetic implant eg. prosthetic hip or knee
Bronchitis, emphysema or other lung disease
Other :
Please list all known allergies (eg penicillin, latex) :
Do you smoke? Yes No How many? /day
For females, are you pregnant or undergoing fertility treatment?
Guardian Name :
Dependents :
Your Signature Date