Microsoft word - health questionnaire
PERSONAL DETAILS (Confidential)
Surname:___________________ First Name:______________________ Title:_______
Address:_____________________________________ Suburb: ______________ Postcode: _____
Home Phone: ________________ Mobile Phone:___________________________________
Business Phone:______________ Email:__________________________________________
Date of Birth:
How did you find out about us: □ Yellow pages □Internet □Word of mouth
□Saw sign/ Building □ Referral from specialist/Dentist________________ □Other__________ Preferred method of contact:
□ Reminder card
Are you happy with the appearance of your teeth?
Doctor’s Name: __________________________
Are you currently being treated for any health
Have you been admitted to hospital in the last two
Do you have or have you had any heart problems
□ Heart Murmur
□ Valve Replacement/Failure
□ Other: _____________
Have you, or any member of your family, ever had excessive bleeding
or bruising: Yes □ No □
Do you smoke?
if you have or have previously had any of the following:
□ High Blood Pressure
□ Lung Disease
□ Liver Problems
□ Hip / Joint Replacement
□ HIV / AIDS
□ Stomach or Bowel Problems
□ Depressive Illness
□ Kidney Problems □ Rheumatic Fever
Are you taking any tablets, medicines, inhalers or injections
of any kind? Yes □ No □
If yes, please list
Have you previously had an allergic reaction
e.g. to pills, medicines (e.g. penicillin), latex or local
If yes, please list:
Females: Are you pregnant?
Appointments not attended or cancelled without 24 hours notice will be charged for.
Payment is required on the day of treatment. If an account is taken away, an administration of 10% will be added.
Any unpaid debt will be forwarded to a collection company, expenses incurred in this process will be charged to the patient.
St Albans Dental Centre reserves the right to discontinue treatment on a patient at our discretion, for any reason.
St Albans Dental Centre reserves the right to take a sample of blood for analysis in the case of a needle stick injury to a staff
I have read the above questionnaire and completed it to the best of my knowledge SIGNED:_____________________________________ DATE: _______________ Relationship to patient (if applicable) _____________________________________
S:\Marketing\Practice Marketing Material\@NZ\St Albans Dental Centre - Platts\Website\Health Questionnaire.doc
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