Port Macquarie (02) 6584 7272
Coffs Harbour (02) 6656 1557
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New Patient Information
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Misc.
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Referral Information
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Health Fund Details
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Is the patient under 18 years old?
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Father’s Name (if patient is under 18)
Mother’s Name (if patient is under 18)
Child lives with (if patient is under 18)
Person Responsible for account
Address (if patient is under 18)
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Consent for X-rays/photos for educational purposes
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Dental Health History
Prefer to save your teeth
Want complete dental care
Are apprehensive about dental treatment
Had problems with previous dental treatment
Happy with the appearance of your teeth
Gums bleed easily
Gums feel swollen or tender
Teeth feel loose
Gums bleed when you floss
Suffer difficulty/discomfort when chewing
Teeth are sensitive
You have missing teeth
You think you may have rapidly decaying teeth
Have lost or broken fillings
Have a dry mouth
Have an unsatisfactory denture
Discoloured teeth
Have a toothache
Grind or clench your teeth
Worn or broken teeth
Suffer pain in the face cheeks jaws joints throat or temples
Hear sounds (clicking) from your jaw
Pain with hot, cold, sweet, or sour food
Take medication for pain
Medical History
Lung condition
Heart condition
Gastrointestinal condition
Nervous or Psychiatric condition
Blood disorders
Blood-borne viruses
Blood Pressure Problem
Bone disease
Back Problems
Neck Problems
Fainting Spells
Eye conditions
High Cholesterol
Immune condition
Tuberculosis or other respiratory disease
Diabetes
Liver disease
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Neurosurgery
Smoking
Prior hormone treatment
Pregnancy
CJD or related diseases
Stroke
Thyroid
Skin Conditions
Epilepsy or Seizures
Dementia
Other ongoing conditions
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Last Name
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Person Responsible for account
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ARE YOU ALLERGIC OR HAVE YOU REACTED ADVERSELY TO ANY OF THE FOLLOWING?
Local Anaesthetics
Penicillin or other antibiotics
Sulphur Drugs
Barbiturates, Sedatives or Sleeping Pills
Aspirin
Codeine
Latex or Rubber Dam
Other
Current Prescription Medications
Current Non-Prescription Medications and Recreational/Lifestyle Medications
Ceased Medication including Recreational and Lifestyle Medication
Do you receive any medications in the form of an injection or implant
Are you seeing any other type of Doctor, Specialist, Healer, Naturopath, etc?
Have you been hospitalised or been in any accidents in the last 12 months?
Have you had any operations or surgery?
Do you have any disabilities?
Have you ever taken any other person’s medications?
Have you been diagnosed with osteoporosis or osteopenia?
Have you got cancer or are you having any cancer related treatment?
Medical Doctor’s Name
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