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Medical History Update Form

to help us prepare for your next visit and save you time please complete this form.

Fields marked * are required.

Patient’s First Name*

Patient’s Surname*

Date of birth*

Parent/Guardian Name (if patient is under 18 years of age)

Medical History Review

Since your last medical history update, have there been any changes to your personal details, dental history or medical history?*

No - There have been no changes since my last medical history update.

Yes - There have been changes. Please complete the relevant sections below.

Personal Details

Have any of your personal details changed? (eg. moved address, name changed)*

Yes

No

If Yes, please provide details:

Dental History

Have you had any changes to your dental history? (e.g. dental treatment, extractions, injuries to teeth, root canal treatment, implants, jaw surgery, missing teeth)*

Yes

No

If Yes, please provide details:

Medical History

Have you had any changes to your medical history? (e.g. new medical conditions, diagnoses, hospitalisations, surgeries)*

Yes

No

If Yes, please provide details:

Medications

Have you started taking any new medications, supplements or changed existing medications?*

Yes

No

If Yes, please provide details:

Allergies

Have you developed any new allergies or sensitivities? (e.g. medications, latex, food)*

Yes

No

If Yes, please provide details:

Treating Healthcare Providers

Are you currently under the care of a doctor, specialist or other healthcare provider for any condition? *

Yes

No

If Yes, please provide details:

Other Information

Is there any other information you feel is relevant to your orthodontic treatment?*

Yes

No

If Yes, please provide details:

Declaration

I declare that the information provided in this medical history update is true and complete to the best of my knowledge. I understand that it is my responsibility to inform the practice of any changes to my medical or dental history, medications or personal details throughout my orthodontic treatment.

I acknowledge that this information will be used by my orthodontist to assist in the safe planning and delivery of my orthodontic care.

Patient/Parent/Guardian Name*

Date*

Please sign here:

For further information about how we use your data, please see our privacy policy.

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Visit our beautiful, new office across from Sydney Street Markets in Mackay. We look forward to welcoming you with a smile!

Contact

1/33 Brisbane Street,
Mackay, QLD 4740

info@torqueortho.com.au

Monday - Thursday: 8:00am to 5:00pm
Friday: 8:00am to 2:30pm

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