Invisible Orthodontics Personal Details & Medical History Form Personal Details Title MrMrsMsMissMasterDrN/A Patient's Full Name Patient's Address Suburb Postcode GenderMaleFemaleTransgenderNon-BinaryIdentifies As If Identifies As Date of Birth Email Address Phone (M) Phone (H) Account Details Payee's Name – Parent / Guardian 1 (person/s responsible for payment of account) Payee's Address Payee's Email Address Payee's Mobile Payee's Name – Parent / Guardian 2 Payee's Address Payee's Email Address Payee's Mobile Do you have a Health Fund with Dental Extras?YesNo If yes, name of Health Fund Do you have a Health Fund with Hospital Cover?YesNo If yes, name of Health Fund Do you have a Medicare card?YesNo Medicare Number Patient ID on Card Expiry Dentist's Name Practice Name Did they refer you?YESNO Doctor's Name How Did You Hear About Us? Who referred you to us, or how did you hear about us?GooglePractice Sign / Drive PastFacebookInstagramOther Other / If word of mouth, please name the person who referred you Medical History Does the patient have a health problem?YesNo If yes, please list Is there a history of serious illness, accident or operation?YesNo If yes, please list Is the patient under a doctor's care for any problem at this time? YesNo If yes, please list Is the patient taking any medication (include all, as most medications interfere with orthodontics)? YesNo If yes, please list Does the patient have any allergies or drug sensitivities? YesNo If yes, please list Dental History Has the patient had an orthodontic consultation previously?YesNo Has the patient had any previous orthodontic treatment?YesNo Has the patient had any injury to the teeth? (includes both baby & permanent teeth)YesNoIf yes, please list Has the patient had any injury to the face, jaw or gums?YesNo Has the patient had any cysts or tumours of the jaws or gums?YesNo Have you been informed of any missing or extra permanent teeth?YesNo Does the patient suck fingers or thumb, or have a similar habit?YesNo Date of last dental examination Reason for seeking orthodontic treatment Medical Checklist ArthritisAsthmaFainting or dizzinessBleeding disordersBone disordersHeart diseases or murmurRheumatic feverCancer or tumourCleft palateEpilepsy or convulsionsHearing problemsEmotional problemsDiabetesSyndromesTonsillitisEndocrine problemsSleep ProblemsJoint problems or painGrindingClenchingSnoringBed wettingSpeech problemsLearning disabilitiesADD / ADHDEDS Consent & Signatures Signature Clear Date
