Medical History Name*FirstLastAddress*Street AddressCityZIP / Postal CodeDOB*DDMMYYYYMobile Number*Home NumberWork NumberPersonal Email*Occupation and CompanyMedical FundNext of Kin *Next of Kin PH no *When was your last dental check up ?What is the reason for today's visit ?Any particular reason you left your last dentist?How often do you brush your teeth ?How often do you floss ?Do you use an electric toothbrush ?What are your long term plans for your Oral Health ?I'm keeping my teeth my whole life!I'm planning on dentures eventually.Would you like to know more about "Happy Gas" ( Nitrous Oxide) to relax you throughout your dental treatment ?YesNoDo you suffer from any of the following ?*Sensitivity to hot/coldStaining of your teethDiscoloured fillingsBleeding gumsBad breathHead/neck acheFood trapping between your teethGrinding or clenching of your teethRoughness of existing fillingsClicking/pain in jaw jointsSensitivity when eatingNone of the Above48 hours notice is required for ALL cancellations or a fee may be charged.*Please confirm you agree.Are you under the care of a medical doctor? If so, please name your regular doctor and location Are you presently taking any medication ? If so, please give details:Do you smoke? If so, how many packs a week ?If female, are you pregnant ?Do you suffer from Sleep Apnoea ?Do You play sports? If so - which ones?Do you suffer from, have, or had any of the following ? *AsthmaDiabetesCardiac ProblemsBlood Pressure ProblemsLiver ProblemsRadiotherapySteroid therapyHIV/AidsPregnantSleep ApnoeaNone of the aboveCan we send you newsletters and updates?*YesNoWho may we thank for this kind referral?Is there anything else you would like to discuss to improve your smile ?I certify to the above statements regarding my medical history. I consent to the advised treatment and the use of anaesthetic and any other required medications. Payment for a ll treatment and services rendered are my responsibilty.*Tick to confirmSignature* Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged.