Uncategorized – Faceworx

Name*
First Name*

First Name
Last Name*

Last Name
Address *

Street Address
City*

City
State / Province*

State / Province
Postal / Zip Code*

Postal / Zip Code
Date of Birth*
DD slash MM slash YYYY
Email Address*
Contact Phone Numbers *

Home Number
Work Number

Work Number
Mobile Number

Mobile Number
Next of kin*

Next of kin *
Contact phone*

Contact phone *

Medicare/DVA Number*
Ref No.*

Ref No. (number before your name)
Private Health Insurance Provider *
Membership No.

Membership No.
Hospital cover?
Hospital cover?
Dental cover?
Dental cover?
Communication *
I authorise the practice to communicate with me via
SMS
SMS
Email
Email
Is the person responsible for paying this account different to the patient? *
Salutation
First name of account holder

First name of account holder
Family name of account holder

Family name of account holder
Relationship to patient

Relationship to patient
Date of birth of account holder
DD slash MM slash YYYY

Date of birth of account holder
Medicare/DVA No. of account holder

Medicare/DVA No. of account holder
Ref No. (number before your name)

Ref No. (number before your name)
I authorise the person paying my account to receive information regarding my treatment
I authorise the person paying my account to receive information regarding my treatment

Medical Questionnaire - private and confidential
The state of your health may have a very significant effect on your dental care. Please answer these questions fully or discuss them with Dr Henze:
I have private medical matters, which I wish to discuss*
Are you receiving any medical treatment at present?*
Height (cm)*
Weight (kg)*
Aspirin*
Warfarin, clopidogrel, heparin or newer generation blood thinning medications*
Treatment for osteoporosis (bisphosphonates) orally or via injection (eg Prolia)*
Cortisone or steroids*

Medical Questionnaire - Private And Confidential
Please indicate YES or No as applicable
Rheumatic fever*
Rheumatic fever
Thyroid disease (including goitre)*
Thyroid disease (including goitre)
Any heart (cardiac) complaint*
Any heart (cardiac) complaint
Tuberculosis (TB)*
Tuberculosis (TB)
Cardiac pacemaker*
Cardiac pacemaker
Asthma/bronchitis/lung conditions*
Asthma/bronchitis/lung conditions
Heart valve replacement/stents*
Heart valve replacement/stents
Any nervous system disorder*
Any nervous system disorder
High or low blood pressure*
High or low blood pressure
Epilepsy (fits)*
Epilepsy (fits)
Gastroesophageal reflux disease (GORD)*
Gastroesophageal reflux disease (GORD)
Excessive bruising or bleeding*
Excessive bruising or bleeding
Radiation therapy*
Radiation therapy
Osteoporosis or low bone density*
Osteoporosis or low bone density
Transplanted organ or bone marrow*
Transplanted organ or bone marrow
Diabetes*
Diabetes
Treatment for any form of cancer*
Treatment for any form of cancer
Hepatitis, jaundice or liver disease*
Hepatitis, jaundice or liver disease
Joint replacement surgery*
Joint replacement surgery
Jaw joint problems*
Jaw joint problems
Allergies*
Allergies
If allergies, please specify

If allergies, please specify
Do you smoke?*
Do you smoke?
What do you smoke? (cigarettes/cigars/pipe/other)

What do you smoke? (cigarettes/cigars/pipe/other)
If yes, for how long?

If yes, for how long?
How much do you smoke per day?

How much do you smoke per day?
Have you ever required any treatment for smoking related diseases or conditions?
Have you ever required any treatment for smoking related diseases or conditions?
Do you suffer from any illness not listed above or carry any infectious disease? (Hep B, Hep C, HIV)*
Do you suffer from any illness not listed above or carry any infectious disease? (Hep B, Hep C, HIV)
If yes, please provide details

If yes, please provide details
Females *
Are you pregnant?
If yes, when are you due?

If yes, when are you due?
Are you breastfeeding?
Are you breastfeeding?

Declaration
In signing this form I acknowledge that this represents an accurate medical history. I will advise the doctor of any changes to my medical history in the future. I understand that all medical details will be treated with complete professional confidentiality.
Patient signature (Parent or guardian if under 18 years)
Date
DD slash MM slash YYYY

Date
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Communication *

Medical Questionnaire - private and confidential

Medical Questionnaire - Private And Confidential

Declaration

Procedures

Categories

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DR FRANC R C HENZE | Specialist Oral & Maxillofacial Surgeon

Patient Questionnaire

Communication *

Medical Questionnaire - private and confidential

Medical Questionnaire - Private And Confidential

Declaration

Procedures

Categories

Archive