Angleseaoms.co.nz

Health History Questionnaire
Confidential
(Mr/Mrs/Ms/Miss)……………………………………………………………………. Date of birth……………………………………… BLOCK LETTERS Address:………………………………………………………………………………………………………………………………………… Home Phone:……………………………………………………………. Work phone:…………………………………………………. Email address:…………………………………………………………… Mobile/Fax:…………………………………………………. Do you want to receive your correspondence by email? Y N Name of referring Dentist?. Name of family Doctor?. How did you hear about us? Yellow pages/White pages/Word of mouth/Referral/Other Do you have Medical Insurance? Y N Name of Company and Policy……………………………………………. Is this consultation accident related? Y N Claim number and date of accident………………………………………. Do you carry a specialist card/bracelet? Y N Please specify………………………………………………………………. What is your weight?. What is your height?. HAVE YOU HAD ANY OF THE FOLLOWING? (CIRCLE Y/N) Heart trouble or heart murmur? What and when? ………………………………………………………………. Y N Rheumatic Fever? What and when? ………………………………………………………………. Y N Jaundice or Hepatitis? What and when? ………………………………………………………………. Y N Diabetes? When? ………………………………………………………………. Y N Asthma? When? ………………………………………………………………. Y N Have you ever had any serious illness? What and when? ………………………………………………………………. Y N ……………………………………………………………………………………………………………………………………. If yes, were you treated in hospital? When?. Have you had any previous operations? What and when? ………………………………………………………………. Y N Have you ever had a full General anaesthetic before? What and when? .………………………………………………. Y N Do you have a history of fainting ………………………………………………………………. Y N Are you taking any pills, tablets or medicine now or in the past 6 months? What and when? ………. ……………………………………………………………………………………………………. Y N Are you currently taking any herbal/natural remedies? Please specify .…………………………………………………. Y N ……………………………………………………………………………………………………………………………………. Are you currently taking WARFRIN, CARTIA or ASPIRIN? Specify how many per day………………………………. Y N Have you ever taken FOSAMAX? Specify when……………………………………………………………………………. Do you use recreation drugs? Specify…………………………………………………………………………………………Y N Are you a smoker? Number per day…………………………………………………………………………………………… HAVE YOU EVER HAD A REACTION TO ANY MEDICINES, INJECTIONS OR STICKING PLASTER?(penicillin or other antibiotic, aspirin, other tables or anaesthetics) please specify ……………………………………………………………………………………………………………………………………. Y N Have you ever had a bad reaction during dental treatment? Specify ……….……………………………………. Y N Have you ever had a bleeding problem? What? ………………………………………………. Y N Are you wearing an artificial or prosthetic joint? Specify type ………………………………………………. Y N Have you any reason to believe that you may be at risk from HIV infection? …………………………………………. Y N Do you believe that you may be at risk from any other disease? …………………………………………. Y N Is there any other health matter your surgeon should know? …………………………………………… Y N FEMALES Are you pregnant? ……………………………………………………………………………………. Y N Are you on the oral contraceptive pill? ……………………………………………………………………………………. Y N Name: (Mr/Mrs/Ms/Miss …………………………………………………………………………………………………… Relationship: i.e Mother/Father ……………………………………………………………………………………………. Address: ……………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………. Work phone:………………………………. Email address …………………………………………………. Mobile/Fax ………………………………… The medical history I have given is true and correct to my knowledge: Signed: …………………………………………………………. Date: ……………………………………………. To be completed by the parent/guardian/caregiver if patient is UNDER 16 YEARS OF AGE Name: (Mr/Mrs/Ms/Miss …………………………………………………………………………………………………… Signed: ………………………………………………………………… DATE:………………………. Medical update: I have read my Health History and confirm that is adequately states past and present conditions. Date: ………………………………………. Signed: …………………………………………………. Date: ………………………………………. Signed: …………………………………………………. Date: ………………………………………. Signed: ………………………………………………….
FINANCIAL AGREEMENT /TERMS OF TRADE
Please read carefully.
I understand that payment is due at the time of treatment unless other arrangements have been made. By accepting services/treatment at this practice you agree to our terms of trade. I hereby agree inconsideration of credit being extended to me to pay ALL collection costs, court costs & solicitor fees in the event that this account becomes overdue.

Source: http://www.angleseaoms.co.nz/assets/Uploads/Health-Questionnaire/Health-History-Questionnaire.pdf