I would like to welcome you to my practice. This questionnaire is confidential and filling out this form helps us provide the best possible care and treatment for you. To optimise your treatment time, please complete and submit this form at least one week prior to your appointment.

Please arrive 15 minutes earlier than the scheduled appointment time to allow for pre-treatment administration.

Antibiotics: If your medical practitioner or medical specialist advised you that your medical condition or joint replacement requires antibiotic coverage prior to dental appointments, then they must be taken prior to a periodontal consultation and or treatment. If the antibiotics were not taken as advised then the examination cannot occur.

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Personal Details

First Name*

Last Name*

Preferred Names

Preferred Salutation or Title*

What is your gender?*

Female

Male

Other

Date of Birth*

Do you require an interpreter?*

Yes

If you are deaf, hard of hearing or speech-impaired and need assistance, Please let our friendly team know when booking an appointment. To ensure staff are confident they are effectively communicating with you, we may request that you contact an accredited interpreter to assist with your appointment. If you need assistance locating an interpreter for your appointment https://www.qits.com.au/ may be able to help.

Mobile Number*

Address*

Street Address City State / Region Postcode

Are you happy to receive information and confirmations by email?*

Yes

I don't have one

Referring Dentist

Do you have a referring dentist?*

Yes

I do not have a dentist

Name*

Phone Number*

Practice Name*

Is this your regular dentist?*

Yes

Please provide your regular or last visited dentist's information below.

Name*

Phone Number*

Practice Name*

GP/Medical Details

Medical Doctor's Name*

Name of Medical Practice*

Medication

Have you ever been advised to take antibiotics prior to dental appointments?*

Yes

Please state when and why you have been advised to take antibiotics.*

Please be aware that if you have been advised to take antibiotics prior to dental appointment, then you must take them prior to a consultation and/or treatment by a periodontist. If not the examination can not occur.

Are you taking any medication, drugs, pills, supplements, herbal remedies or vitamins? (prescription or over the counter)? So that we can take appropriate precautions and avoid drug interactions.*

Yes

Please list any medications that you may be taking:*

Drug Name

Dose

Commencement date of Treatment

Purpose

To add additional information, please click on the + icon, which will add a new line.

Have you taken any medications in the last ten years in particular Steroids or Bone affecting medications / injections?*

Yes

Medication Details*

Drug Name

Dose

Commencement date of Treatment

Purpose

To add additional information, please click on the + icon, which will add a new line.

Are you aware of any allergic or adverse reaction to any medical or substance?*

Yes

Please list the medicine or substance:*

Please describe the reaction to that medicine or substance:*

Have you ever had an adverse reaction to local anaesthetic or general anaesthetic?*

Yes

Please explain adverse reaction to local anaesthetic or general anaesthetic*

Have you had any dental implants placed since your last appointment?*

Yes

When did you get them?*

Where are they?*

Are you happy with them?*

Yes

Who placed them for you?*

What brand are the implants (if known)?

Medical Conditions

What is your weight in kilograms? (The doctor uses this information for anesthetic purposes).*

Please record your weight using numbers only.

Do you have or have you ever had any of the following conditions?

Anaemia*

Yes

Arthritis / Rheumatism*

Yes

Please state type of arthritis?*

Artificial Joints (hip, knee, etc)*

Yes

Please list the location and date of the joint replacement:*

Location of Replacement (e.g. hip, knee etc)

Date of Replacement

To add additional information, please click on the + icon, which will add a new line.

Asthma / Hay Fever / Respiratory Conditions*

Yes

Autoimmune / Immune disorders*

Yes

Please describe Autoimmune / Immune Disorders*

Cold Sores / Fever / Blisters*

Yes

Cancer*

Yes

Please list and give dates:*

Type of Cancer

Date of Diagnosis

To add additional information, please click on the + icon, which will add a new line.

Chemotherapy / Radiation Treatment*

Yes

Please note any surgical procedures or type of chemotherapy or radiation and the date of that procedure that you have undergone since your last visit with us*

Treatments

Date of Treatments

To add additional information, please click on the + icon, which will add a new line.

Chronic Cough*

Yes

Emphysema*

Yes

Blood Disorders*

Yes

Please specify what type of blood disorder:*

Blood Borne disease such as Hepatitis B or C or D/HIV/AIDS*

Yes

Please explain your Blood borne disease such as Hepatitis B or C or D or HIV / AIDS*

High risk for blood borne disease*

Yes

Haemophillia*

Yes

Type of Haemophillia?

Blood in Urine*

Yes

Bleed easily or have nosebleeds*

Yes

Bone disorders including osteoporosis or osteopenia*

Yes

Please indicate which condition*

Osteoporosis

Osteopenia

When was your bone disorder first diagnosed?*

Bone Marrow Disorders*

Yes

Please specify the type of bone marrow disorder:*

Ear Problems*

Yes

Please explain your ear problems*

Dry Eyes*

Yes

Glaucoma*

Yes

Diabetes*

Yes

Type of Diabetes*

Type 1

Type 2

Please advise of the date of Diabetes diagnosis?*

When was your glycosylated haemoglobin levels tested last?*

What is your glycosylated haemoglobin levels?*

Depression*

Yes

Dry Mouth*

Yes

Frequency*

Epilepsy or Seizures*

Yes

Fainting or Dizzy Episodes*

Yes

Frequent Colds or Sore Throat*

Yes

Headaches*

Yes

What type and how frequent are the headaches?*

Type of Headache

Frequency of Headache

To add additional information, please click on the + icon, which will add a new line.

Hepatitis A / B*

Yes

Type*

Congenital Heart disease*

Yes

Angina / Heart Pain*

Yes

Rheumatic Fever*

Yes

Heart Stents*

Yes

When was it placed?*

Heart Murmurs*

Yes

If yes, are these benign or require antibiotic coverage?*

Benign

Require antibiotic coverage

Surgical corrections to heart – heart valve or bypass*

Yes

Please provide details:*

What was the procedure?

When was this performed?

To add additional information, please click on the + icon, which will add a new line.

Mitral Valve Prolapsed*

Yes

What was the date of prolapse?*

Kidney Disease*

Yes

Please state the kidney disease problem*

Liver Disease / Jaundice*

Yes

Please state the liver disease problem?*

Nervous / Anxiety*

Yes

Neurological Disorders*

Yes

Please state the Neurological Disorder*

Reflux / Vomiting*

Yes

Swollen Ankles*

Yes

Stomach Ulcers*

Yes

Please state the stomach ulcer problem?*

Sinus Problems*

Yes

Sudden Weight Change*

Yes

Thyroid Problems*

Yes

If you have thyroid problems, please state what is the problem?*

Tuberculosis / Pneumonia*

Yes

What was the condition?*

Tuberculosis

Pneumonia

When did the condition occur?*

Tumours*

Yes

Please advise the type, location and treatment performed*

Visual Disturbances*

Yes

Please tell us more about your visual problem*

Blood Pressure*

Yes

Please indicate if it is high or low:*

High

Low

Are you on a GP-advised low Sodium Chloride diet?*

Yes

Do you smoke cigarettes?*

Yes

How many cigarettes do you smoke daily?*

Please state what you are smoking

How much are you smoking?

How long you have been smoking for?*

Do you vape?*

Yes

Please advise of the vaping dosages used weekly*

Please state what you are vaping

How long you have been vaping for?*

Is nicotine present in your vape?*

Yes

Do you smoke any other substances?*

Yes

Please advise of what and quantity weekly?*

Any previous operations either medical or dental?*

Yes

Please list all operations and their date since your last medical history for Coastal Periodontics was filled out?*

Operation

Date of Operation

To add additional information, please click on the + icon, which will add a new line.

Do you have or have had any diseases, conditions or problems not listed?*

Yes

Please provide details:*

Are you or do you think you maybe pregnant?*

Yes

Number of months of pregnancy?*

Have you previously been pregnant?*

Yes

Are you currently breastfeeding?*

Yes

Have you had your Covid-19 vaccination?*

Yes

Please select which vaccinations you have had:

First Dose

Second Dose

Booster

I hereby declare, that all of the information I have provided is complete and correct. I am aware that missing or incomplete information, whether deliberate or the result of negligence, may prevent Dr Bourke from accurately assessing and treating my periodontal status and may cause harm to my overall health.*

Yes

Hidden

Today's Date

DD slash MM slash YYYY

By submitting this form you are agreeing to the following terms and conditions:

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider, who may release such information to you. I will notify you of any changes in my health or medication.

To complete the form, you must press the Submit button below.

Phone

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Update Medical History

Personal Details

Referring Dentist

GP/Medical Details

Medication

Medical Conditions

Do you have or have you ever had any of the following conditions?