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Dr Peter Lewis
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Dental History
When was your last check-up?
Dental check-up frequency:
Twice a year
Once a year
Emergencies only
Never
Any previous trauma to you face or teeth?
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Any periodontal / gum disease?
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Any problems with your jaw joints?
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Orthodontic History
What concerns you about your teeth?
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Previous Treatment
Consultation Only
Medical History
Heart Murmur:
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No
Rheumatic Heart Disease:
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No
Bleeding Disorders:
Yes
No
Blood Pressure:
High
Low
Asthma:
Yes
No
Eczema:
Yes
No
Diabetes:
Yes
No
If yes, what type?
ADD / ADHD:
Yes
No
Epilepsy:
Yes
No
Tuberculosis:
Yes
No
Hepatitis:
Yes
No
If yes, what type?
HIV or AIDS:
Yes
No
Other Medical Conditions:
Yes
No
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Allergies:
None
Penicillin
Latex
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Medications, Supplements or Drugs taken:
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Yes
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Patient Information
Title:
Mr
Mrs
Ms
Miss
Full Name:
Date Of Birth:
Home Phone:
Work Phone:
Mobile:
Address:
Suburb:
Postcode:
School / Uni:
Year:
Occupation:
Date:
Email:
Parent Information (If Applicable)
Title:
Mr
Mrs
Ms
Miss
Full Name:
Home Phone:
Work Phone:
Mobile:
Title:
Mr
Mrs
Ms
Miss
Full Name:
Home Phone:
Work Phone:
Mobile:
Person Responsible For Accounts
Full Name:
Address:
Suburb:
Postcode:
Dentist
Name:
Suburb:
Consent for us to communicate with your dentist?
Yes
No
Dental History
When was your last check-up?
Dental check-up frequency:
Twice a year
Once a year
Emergencies only
Never
Any previous trauma to you face or teeth?
Yes
No
Any periodontal / gum disease?
Yes
No
Any problems with your jaw joints?
Yes
No
Orthodontic History
What concerns you about your teeth?
Parent's Orthodontic Treatment:
None
Mother
Father
Patient's Orthodontic Treatment:
None
Previous Treatment
Consultation Only
Medical History
Heart Murmur:
Yes
No
Rheumatic Heart Disease:
Yes
No
Bleeding Disorders:
Yes
No
Blood Pressure:
High
Low
Asthma:
Yes
No
Eczema:
Yes
No
Diabetes:
Yes
No
If yes, what type?
ADD / ADHD:
Yes
No
Epilepsy:
Yes
No
Tuberculosis:
Yes
No
Hepatitis:
Yes
No
If yes, what type?
HIV or AIDS:
Yes
No
Other Medical Conditions:
Yes
No
If yes, please list below:
Allergies:
None
Penicillin
Latex
Other
Other allergies:
Medications, Supplements or Drugs taken:
None
Yes
If yes, please list below:
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