Patient Information PATIENT DETAILS Please leave this field empty. Title Select your titleMrMrsMissMsMasterProfDr Surname (required) Full Names (required) Initials (required) ID / Passport Number Date of Birth Gender Select your genderFemaleMale Marital Satus Select your marital statusMarriedSingle Employment Satus Select an optionWorkingStudentScholarOther 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 Select an optionEmailPhone REFERRAL Reffered by Select an optionGoogleOther PractitionerFriendWhatClinicWebsite Referral name PERSON RESPONSIBLE FOR ACCOUNT Medical Aid Medical Aid Plan Medical Aid Number Main Member Name Main Member ID Number 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) Do you smoke?NoYes 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 pregnant or breasfeeding?NoYes Are you allergic to latex? Please select an optionNoYes Have you ever had a bad reaction to local anaesthetics? Please select an optionNoYes Please list any drug allergies Please list any medication you are currently taking at the moment Please leave this field empty. 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? Please select an optionOnce a DayTwice a DayMore than twice a Day How often do you floss? Please select an optionI don'tOnce a WeekOnce a DayTwice a Day Do your gums bleed when you brush or floss? Please select an optionNoYes Please leave this field empty. Does food or floss catch between your teeth? Please select an optionNoYes 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. Please leave this field empty.