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Patient profile

SYDNEY ORAL MEDICINE

YOUR DETAILS (Please print clearly)
Title. . . . . . . . . .Surname………………………Given Names…………………….……. Date of birth………….……………………………. Gender: □ Male □ Female Address………………………………………………………………………………….… Suburb……………………………….State……………Postcode….….… Telephone:.(H)………………………………….(M)……………………………………… (B)………………………………………Occupation. Email………………………………………………………………………………………. NEXT OF KIN/PERSON TO CONTACT IN EMERGENCY
Name:………………………………….Relationship to patient…………………………. PRIVATE HEALTH INSURANCE & MEDICARE
Do you have Private Health Insurance with Dental cover? □ Yes □ No Medicare card no…………………………….Ref.no………………Expiry date………… Person responsible for accounts (if not self)……………………………………………….
Are you happy for us to confirm your appointments via SMS on your
mobile?

If not, would you prefer: □ Email □ Phone

Referring Doctor:

.

YOUR MEDICAL HISTORY
Please tick “Yes” if you have now, or have had in the past, any of the following: Heart condition or murmur □ Yes □ No Muscle, bone, joint problems □ Yes □ No Rheumatic fever □ Yes □ No Immune system problems □ Yes □ No High blood pressure □ Yes □ No Gastrointestinal problems □ Yes □ No Bleeding problems □ Yes □ No Urogenital problems □ Yes □ No Respiratory problems □ Yes □ No Liver problems □ Yes □ No Nervous system problems □ Yes □ No Cancer □ Yes □ No Thyroid problems □ Yes □ No Pregnancy □ Yes □ No Diabetes □ Yes □ No Smoking □ Yes □ No Infectious diseases □ Yes □ No Alcohol □ Yes □ No Osteoporosis □ Yes □ No Betel nut use □ Yes □ No Medications………………………………………………………………………………… ……………………………………………………………………………………………… Have you ever been prescribed any of the following medications? Zometa™, Pamidronate™, Bonefos™, Actonel™, Fosamax™ . Hospital admissions………………………………………………………………………. ……………………………………………………………………………………………… Allergies…………………………………………………………………………………….
.……………………………………………………………………………………………. Other…………………………………………………………………………………….…
FAMILY DOCTOR’S DETAILS
Doctor’s Name……………………………………………………………………………. Address……………………………………………………………………………………. Telephone………………………………………………………………………………….

Source: http://www.sydneyoralmedicine.com.au/som-patient-profile-medical-history.pdf