Orofacial Pain and Dysfunction form - Perth Oral Medicine & Dental Sleep Centre

Title

Surname*

First Name*

Occupation

Date of Birth*

Address*

Street Address Suburb ZIP / Postal Code

Telephone (M)*

Telephone (H)*

Email Address*

Work Details*

(W)*

Emergency Contact/Next of Kin*

Relationship*

(M)*

(H)*

Medicare No

Ref

Exp

HCC/Pensioner

Exp

Department of Veteran Affairs

Colour

Exp

Private Health*

Insurer Name*

General Practitioner*

(W)*

Address*

Street Address

Dentist*

(W)*

Address*

Street Address

Referred by*

General Practitioner
Dentist
Other (Details below)

Name*

(W)*

Address*

Street Address

Please Tick YES / NO / DETAILS

Are you taking any tablets or medications (prescribed or overthe- counter) at present? Please specify.

Details

Do you normally require antibiotic cover for surgical procedures?*

Details

Do you have any known allergies (penicillin, drugs, latex or foods)?*

Details

Do you have any known allergies (penicillin, drugs, latex or foods)?*

Details

Have you had any reactions to local or general anaesthesia?*

Details

Do you smoke? If so, how many per day, and for how many years?*

Details

Do you smoke? If so, how many per day, and for how many years?*

Details

Are you a past smoker? If so, how many did you smoke and for how many years? When did you stop smoking?*

Details

Do you drink alcohol on a regular basis? If so, how many per day, and for how many years?*

Details

Do you use mouthwash on a regular basis? If so, what brand and how many times daily?*

Details

What brand of toothpaste do you use and how many times daily?*

Details

DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS? (Please tick)

Heart disease*

Yes
No

Cancer*

Yes
No

Hepatitis or liver disease*

Yes
No

Heart valve disorder*

Yes
No

Steroid therapy*

Yes
No

Epilepsy*

Yes
No

Rheumatic fever*

Yes
No

Diabetes*

Yes
No

Muscle disorder*

Yes
No

Cardiac pacemaker*

Yes
No

Kidney disease*

Yes
No

Anxiety*

Yes
No

High/low blood pressure*

Yes
No

Thyroid disease*

Yes
No

Depression*

Yes
No

Skin condition*

Yes
No

Tuberculosis*

Yes
No

Prosthetic joint*

Yes
No

Radiation therapy*

Yes
No

Excessive bleeding*

Yes
No

Asthma*

Yes
No

Autoimmune disease*

Yes
No

Anaemia, Leukaemia or other blood disorder*

Yes
No

Bronchitis or lung diseases*

Yes
No

Do you have any other medical conditions? If yes, please list all other medical conditions.*

I agree to the privacy policy.

Privacy Statement: We value your privacy. All of the information, which you provide to us, will be held and used by us in accordance with our Privacy Policy. A copy of our Privacy Policy is attached to this clipboard. Please take the time to read through our Privacy Policy before answering the Questionnaire and speak to one of our staff members if you have any concerns about how we will use your personal information.
1. Please answer the following questionnaire truthfully and to the best of your ability. If ever your health status or medications change, please inform your practitioner at the next appointment.
2. Practice policy is all accounts are settled on the day, immediately after seeing the practitioner.
3. Please note that Medicare rebates are not available. Rebate for services are only available from Private Health Funds. We do not process Private Health Fund rebates for patients at the rooms.
4. The practitioners are not "preferred providers" of any Private Health Fund and have no control over your rebate received.
5. Patients will be charged for missed and late cancellation appointments unless cancelled 24 hours prior to the consult time. DVA, Workers’ Compensation and Motor Vehicle Accident patients will be charged privately for appointments not kept.
6. Some consultations and procedures may not be claimable under Workers’ Compensation, Third Party or General Insurance. We will assist you in directing your bills to the relevant insurance body/solicitors for settlement. However, you are ultimately responsible
for the account irrespective of any disputes with the insurance companies.
7. Please ensure the above information regarding health practitioners involved in your care is current and complete. Correspondence will be sent to all health practitioners listed unless you advise us otherwise.
8. We would appreciate notification of any change of address.
9. CCTV (video only) operates in these premises for security reasons only and not for patient records.
10. I consent to allow my de-identified clinical information and photographs to be used for educational purposes.

I declare that the particulars and information provided are true and correct, and I understand and agree to the above conditions. Further, I hereby authorise Perth Oral Medicine & Dental Sleep Centre and its practitioners, to obtain and release information about my condition to assist in my treatment and/or rehabilitation.

Patient/Guardian Signature*

Date

(If under 18 years): Guardian Name

Guardian Address

Phone