Patient Information

    THE BASICS

    Title

    Surname (required)

    Full Names (required)

    Initials (required)

    ID Number

    Date of Birth

    Gender

    Marital Satus

    Employment Satus

    Description

    ADDRESS

    Home Address

    Address Line 1

    Address Line 2

    City

    Postal Code

    Postal Address

    Address Line 1

    Address Line 2

    City

    Postal Code

    CONTACT INFORMATION

    Home Number

    Work Number

    Cell Number

    Email

    Preferred Contact Method

    REFERRAL

    Referral

    Who

    PAYMENT

    Medical Aid

    Medical Aid Plan

    Medical Aid Number

    Main Member Name

    Main Member Date of Birth

    APPOINTMENT INFORMATION

    Purpose of visit

    Dental EmergencyScale and polish (dental cleaning)Full check-­‐upCosmetic dentistry consultationOrthodontic consultationImplant consultation

    Past Experience

    Previous bad experience at the dentistAnxiety associated with dental treatmentNot happy with my smileNot happy with the colour of my teethI love my teethNeed general advise on toothbrush, toothpaste, floss, whitening etc.

    PREVIOUS MEDICAL HISTORY

    HAVE YOU HAD OR HAVE ANY OF THE FOLLOWING

    Previous orthodontic treatment braces or platesClicking, popping or discomfort in the jawAware of grinding or clenching of your teethSleep apneaDry mouthBad breathHistory of periodontal (gum) treatmentsProblems associated with previous dental treatmentSerious injury to your head or mouth

    Serious injury to your head or mouthTeeth sensitive to hot cold or sweetHead, neck, jaw pain, or achesGastric refluxSnoringMouth breathingMouth ulcers or soresBulimiaSpeech problems

    Do you smoke(including E-cigarettes)

    How many per day

    PRE-EXISTING CONDITIONS

    DO YOU HAVE ANY OF THESE PRE-EXISTING CONDITIONS

    Rheumatic feverHIV/AidsKidney diseaseFrequent head achesPacemakerLow blood pressureHeart valve replacementJaundice
    AsthmaCancerDiabetesTuberculosisVenereal diseaseAnemiaChemotherapyStroke
    HepatitisBleeding disordersPsychiatric treatmentEpilepsyHigh blood pressureJoint replacementRadiotherapyChronic Sinusitis

    Name of treating physician

    Contact Number

    Are you pregnant or breastfeeding?

    Are you allergic to latex?

    Have you ever had a bad reaction to local anaesthetics?

    Please list any drug allergies

    Please list any medication you are currently taking at the moment

    Any other conditions that you think we need to be aware of

    GENERAL DENTAL INFORMATION

    Last Visit To a Dentist

    Last Dental Cleaning

    Last Dental X-rays Taken

    Last Dentist

    DENTAL HABITS

    How often do you brush your Teeth?

    How often do you floss?

    Do your gums bleed when you brush or floss?

    Does food or floss catch between your teeth?

    Fee structure for the practice

    This practice is contracted out of medical aid and therefore does not claim from any medical aid. The patient is responsible for the full account, which has to be settled immediately after the appointment.

    I understand and agree to the terms regarding payment.

    I agree that the information is correct, and that will make known any changes to the treating doctor.

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