Medical History Form

If you are a new patient, you can save time by printing and completing our Medical History Form and bringing it with you to your appointment.

Contact Details


Last Name

First Name

Preferred Name

Date of Birth



Post Code

Phone (h)

Phone (w)

Phone (m)



Place of Employment


Payment / Health Fund Details

Name of person/s responsible for paying your accounts:

Do you have Private Health Insurance? If Yes, which fund?


Medical Information

Have you had any of the following: (Please check the options that apply)

AnginaAsthmaBack ComplaintsBlood Pressure (high or low)DiabetesBlood Disorders
EpilepsyHepatitisHeart AilmentsHeart MurmurCardiac PacemakerHayfever
High risk of HIVMalariaOsteoporosisRheumatic FeverGastric UlcerSmoke
StrokeHeart AttackJoint ReplacementRadiation Therapy


Do you have any other medical conditions?

Are you pregnant? If so, when is your expected due date?

Have you had a reaction to Local Anaesthetics?

Do you have any Drug Allergies?

Are you currently receiving medical treatment? If so, please give details:

Are you currently taking any medications?

When was your last visit to the Dentist?

Do you require antibiotic prophylactic cover?


What is the reason you have made this appointment?

How did you hear about Perth City Dental Surgery?

I understand failure to complete Medical Information may place myself and others at medical risk

I give my consent to receive Dental Treatment by my nominated Health Care Provider

In accordance with the Privacy Act 2001, the only time we reveal any of your personal details is when we have to refer you to a Specialist (Dental/Medical), Debt Collection Agency, for General Anaesthetics (Hospital and Anaesthetist/s).