Patient Welcome and Questionnaire

Welcome to the Sydney Dental Centre. Holistic Dentistry relates your oral heath to your general health. Please complete the confidential questionaire enclosed. Patient Welcome and Questionnaire Sydney.

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Any surgical or invasive procedure carries risks. Before proceeding with a surgical or invasive procedure, you should seek a second opinion from an appropriately qualified health practitioner.

Anxious Patients Cracked Teeth Tooth Whitening Root Canal Dental Implants Cosmetic Dentistry

Follow Us:

Regular check-up and clean	Cosmetic concerns	Holistic approach to your health
Amalgam removal	Dental implants	Pain
2nd Opinion	Consultation for headaches, neckaches or jaw pain
Snoring/Sleep Apnoea	Other

Surname:*		Title:*
Given Name(s):*		Date of Birth:
Ph (home):*		Ph (work):
Mobile number:		E-mail:*
Home Address:
Postcode:*		Occupation:
Note: If the patient is a minor please note below the name of the parent or guardian completing this:
Surname:		Title:
Given Name(s):		Phone:

Whom may we thank for referring you to our practice?
Name of the person
If not a direct referral, how you heard about Sydney Holistic Dental Centre:
Other

Bleeding gums	Do you floss your teeth?
Teeth feel sensitive to: Hot Cold	upper lower left right front teeth
Orthodontic treatment	Root Canal treatment	Periodontal gum surgery
Trigeminal Neuralgia	Difficulty swallowing	Metal taste in mouth
Dry mouth/Excessive saliva	Cold sores (herpes)	Mouth ulcers
Clenching or grinding teeth	Bite feels uncomfortable	Clicking of the jaw left right
Jaw has locked: Closed Open	Jaw aches	Ringing/Popping in ear
Tension neckaches	How often	How long has this gone on
Tension headaches	How often	How long has this gone on
Do you wake in the morning with a headache?
Migraines	How often	How long has this gone on
Cigarettes/day	Coffee/day
Sleeping Position:	Stomach Side Back
Do you snore	Do you fall asleep while watching TV or reading

Are you happy with
Appearance of your teeth:	Yes No
Existing crowns, bridges or dentures:	Yes No
Ability to eat:	Yes No
Tooth cleaning technique:	Yes No
Smile:	Yes No

Would you like an explanation about tooth whitening	Yes No
Would you like an explanation regarding fresh breath therapy?	Yes No
Would you like an explanation about our snoring appliance?	Yes No
How long since your last dental visit?
Would you describe yourself as a relaxed dental patient?	Yes No
Have you seen or are you aware of Dental Hygienists?	Yes No
Is there anything about previous dental experiences you`d like us to know?

Blood pressure high/low	Heart problems	Tachycardia/palpitations	Rheumatic Fever
Kidney problems	Anaemia	Swollen ankles/feet/hands	Liver problems
Hepatitis A/B/C/other	HIV	Cancer	Diabetes
Thyroid problems	Chronically tired	Chronic fatigue	Glandular Fever
Chronic Sore throat	Asthma	Pneumonia	Sinus problems
Frequent infections	Fungal Infection(candida/thrush)		Arthritis
Muscle Soreness/Spasms/Cramps	Back Problems	Numbness or tingling Hands/Feet
Parkinson's disease	Multiple Sclerosis	Epilepsy	Shingles
Digestive Problems	Reflux/Heartburn	Ulcers Stomach/Duodenum	Eye problems
Operations/General Anaesthetics
Other conditions
Approximately when was your last medical check up
Are you currently seeing a health professional for any health problems? Yes No
If you would like us to inform your GP or other health professional(s) of your treatment with us as it relates to your general health, please include the name of these practitioners
Are you taking any medications or supplements?
Are you allergic to anything?

Patient Welcome and Questionnaire

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