www.smileinstyle.com.au - Medical History Update Form

Medical History Update Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Information
Title
Gender *
Please specify
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Day Month Year
Date
Home Address *

Street Address Line 2
Suburb *

Suburb

Street Address Line 2
State *
Postcode *

Street Address Line 2
Home Phone Number *
Mobile Phone Number
Work Phone Number
Email Address *
example@example.com
Occupation
Health Insurance
Member ID Number
Contact person in case of emergency
Phone/Mobile Number
Would you like to subscribe to our newsletter? *

Yes No
Medical History
Are you being treated for a medical condition? *

Yes No
If Yes, Explain *
Medical Doctor's Name

First Name Last Name
Doctor’s Address *

Street Address Line 2
Suburb *

Street Address Line 2
State *
Postcode *

Street Address Line 2
Phone Number
Are you taking any medications or supplements at present, both prescribed or over the counter? *

Yes No
If Yes, Please list *
Are you taking any bisphosphonate medication or any other medication to treat osteoporosis? *

Yes No
If Yes, Explain *
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 Leukemia, cancer Nervous condition Heart complaint 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 Heart complaint or heart surgery Other
Do you have allergies? *

Yes No
What reaction do you have to allergies, please list. *
Do you smoke? *

Yes No
How many /day?
Are you pregnant or undergoing fertility treatment? *

Yes No
If Yes, Explain *
Guardian Name *

First Name Last Name
Dependents
Your Signature *

Clear
Date *

Day Month Year
Date
Please verify that you are human *
Should be Empty:

Medical History Update Form

Patient Information

Medical History