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.

MEDICAL HISTORY QUESTIONNAIRE

- Personal
  details
- *Full Name*
- Date of birth*
  Date Format: MM slash DD slash YYYY
- Your medical doctor*
- Your email address*
- Medical
  History
- 1. Are you receiving any medical treatment at the present time?
  - yes
  - no
- 2. Have you ever been admitted to hospital at any time?
  - 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.
  - Rheumatic fever
  - Epilepsy
  - Heart condition
  - Anaemia
  - High or low blood pressure
  - Bleeding disorder
  - Asthma
  - Tuberculosis
  - Arthritis
  - Gastric problems
  - Chest problems
  - Cold sores
  - Hepatitis A, B or C
  - Kidney problems
  - Migraine headaches
  - Diabetes
  - Other:
- Other
- 4. Are you taking any tablets, medicines or drugs?
  - yes
  - no
  If yes, please list:
- List
- 5. Have you any allergies that you are aware of?
  - yes
  - no
  If yes, please list:
- List
- 6. Have you ever experienced excessive bleeding or bruising from cuts, scratches or dental treatment?
  - yes
  - no
- 7. Have you ever had contact or been at risk with the AIDS virus?
  - yes
  - no
- 8. Have you ever had a reaction to an anaesthetic?
  - yes
  - no
- 9. Are you, or have you ever been a smoker?
  - No, never
  - Yes, but I've quit
  - Yes, I smoke
- 10. Women, are you pregnant or breastfeeding at the moment?
  - yes
  - no
  If pregnant, when are you due?
- Due
- 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 consent to the procedure being done under local anaesthesia with intravenous sedation, as previously explained to me.
  3. I understand the issues and possible complications of this procedure.
- Signature – draw with your finger or mouse in the box below:
- Date
  Date Format: MM slash DD slash YYYY
- Name of parent or guardian:
- Parent / guardian’s signature – draw with your finger or mouse in the box below:
- Date
  Date Format: MM slash DD slash YYYY
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REMUERA, AUCKLAND

© 2019 Auckland Periodontics + Implants
Crafted by Inkwell.

SERVICES

Gum disease
Aesthetic problems
Dental Implants

RESOURCES

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LOCATION

5 St. Marks Road, Remuera
4 Halver Street, Manurewa

OPEN HOURS

Monday to Friday:
8.00am – 5.00pm

Phone: 09 529 7949

NO REFERRAL NECESSARY

COVID-19 (coronavirus) Pandemic: To find out how we are responding and how it may affect your treatment, click here.