Health Questionnaire | Treatment - Auckland Periodontics + Implants

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Confidential health questionnaire

In order to provide the best and safest dental treatment, we need to know of any medical problems which may affect your treatment.

CONFIDENTIAL HEALTH QUESTIONNAIRE

- Personal
  details
- *Title*
- Name*
  First Last
- Address
- Phone (mobile)
- Your email address*
- Date of birth*
- Occupation
- Emergency contact name*
- Emergency contact phone*
- Referred By
- Your medical doctor*
- ACC #
- Date of Accident
- Medical
  History
- 1. Are you receiving any medical treatment at the present time?
  - yes
  - no
- 2. Have you been admitted to hospital in the last 2 years?
  - yes
  - no
  If yes, please state why:
- Why
- 3. Have you had, or do you currently have, any of the following? Select all that apply.
  - Heart condition
  - Diabetes
  - Anaemia
  - Rheumatic fever
  - Kidney problems
  - Bleeding disorder
  - High or low blood pressure
  - Hepatitis A, B or C
  - HIV
  - Chest problems
  - Gastric problems
  - Asthma
  - Epilepsy
  - Other (eg cancer treatment)
- Other
- 4. Do you have Osteoporosis or Osteopenia?
  - Yes
  - No
  - N/A
- 5. Have you ever experienced excessive bleeding or bruising from cuts, scratches or dental treatment?
  - yes
  - no
- 6. Have you ever had a reaction to an anaesthetic?
  - yes
  - no
- 7. Are you taking any tablets, medicines or drugs?
  - yes
  - no
  If yes, please list:
- List
- 8. Have you any allergies that you are aware of?
  - yes
  - no
  If yes, please list:
- List
- 9. Are you, or have you ever been a smoker?
  - No, never
  - Yes, but I've quit
  - Yes, I smoke
- 10. Are you pregnant or breastfeeding at the moment?
  - Yes
  - No
  - N/A
  If pregnant, when are you due?
- Due
- This field is hidden when viewing the form
  x. Have you ever had contact or been at risk with the AIDS virus?
  - yes
  - no
- This field is hidden when viewing the form
  x. Do you take Prolia or Bisphosphonates?
  - Yes
  - No
  - N/A
- 11. Are there any other aspects of your health that you think we should know about?
- Consent
- 1. The medical history I have given is true and correct to the best of my knowledge.
  2. I am happy for my anonymised record to be used for education purposes.
  3. PAYMENT AND CANCELLATIONS: Payment is required IN FULL on the day of the appointment/treatment. In complicated cases with multiple appointments, part payment is required as the treatment progresses. All fee estimates are based upon conditions viewed at the time of diagnosis. Unforeseen circumstances can alter an estimated fee. We understand that sometimes it is necessary to change your schedule. Out of consideration for others, we kindly ask you to provide a minimum of 24 hours notice if you wish to change or cancel an appointment. A fee of $150 will be charged for non-attendance or cancellation on the day of the appointment.
- Signature – draw with your finger or mouse in the box below:
- Name of parent or guardian if you are under 16 years old:
- Parent / guardian’s signature – draw with your finger or mouse in the box below:
This field is hidden when viewing the form
Date of birth [archived]
Month
Day
Year
This field is hidden when viewing the form
*Full Name
Phone
This field is for validation purposes and should be left unchanged.

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with us

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REMUERA, AUCKLAND

TAKAPUNA, AUCKLAND

© 2019 Auckland Periodontics + Implants
Crafted by Inkwell.

SERVICES

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Aesthetic problems
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LOCATION

5 St. Marks Road, Remuera

39 Taharoto Road, Takapuna

OPEN HOURS

Monday to Friday:
8.00am – 5.00pm

Phone: 09 529 7949