4.9

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Cannington

(08) 9258 8440

Margaret River

(08) 9758 8150

REFER TO US

Cannington (08) 9258 8440

Margaret River (08) 9758 8150

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- Cannington
- Margaret River

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Medical And Dental History (Adults)

Name: Carousel Orthodontics
Telephone: (08) 9258 8440

To enable us to diagnose and treat you at the highest standard of care, please answer the following questions as accurately as possible.

Patient details

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Patient First Name*

Patient Last Name*

Gender

Male

Female

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If not listed, please give preferred gender identification

Preferred Pronoun

She

They

Other

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Patient DOB*

Contact Mobile Phone

Contact Email*

Address

Suburb

Postal Code

Occupation

Home/Work Number

Name of Private Health Insurance Provider (if any)

Name of General Dentist

Dental Clinic

Has your dentist given you a referral to see an orthodontist?

Yes

*If yes, please ensure a copy is sent to us before your appointment

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Medical history

Have you previously had or currently having any chronic health problems?

Yes

If yes, please describe

Are you currently under the care of any specialist medical practitioners?

Yes

If yes, please list

Are you currently taking any regular medications?

Yes

If yes, please list

Are you Allergic to anything?

Yes

If yes, please list

Do you have any airway/breathing/snoring/sleep apnoea issues?

Yes

If yes, please describe

Have you had any psychological or nervous disorders?

Yes

If yes, please describe

Do you smoke cigarettes?

Yes

Do you consider yourself to currently be in good health?

Yes

Is there a chance you may be pregnant?

Yes

If YES, how many months

Do you have any of the following health issues

ADD/ADHD

Yes

Diabetes

Yes

Asthma

Yes

Epilepsy

Yes

Autism/Aspergers

Yes

Heart or Blood Pressure Problems

Yes

Blood/Bleeding Disorders

Yes

Hepatitis B/HIV

Yes

Cleft Lip or Palate

Yes

Kidney or Liver problems

Yes

Congential Birth Defects/Syndromes

Yes

Osteoporosis

Yes

Depression

Yes

Speech or Hearing problems

Yes

Is there any relevant information or other medical conditions not listed above that should be brought to our attention?

Yes

If yes, please describe

Dental History - Have you had any of the following?

Chronic Mouth breathing

Yes

Jaw Joint (TMJ) clicking or locking

Yes

Clenching or Grinding of Teeth

Yes

Oral Habits

Yes

Dental or Facial Trauma

Yes

Previous Orthodontic Treatment

Yes

Frequent Mouth Ulcers

Yes

Tooth Decay or Fillings

Yes

Gum Disease

Yes

Wisdom tooth extractions

Yes

Is there any relevant information or other dental issues not listed above that should be brought to our attention?

Yes

If yes, please describe

Approximate date of last general dental check and clean

Regularity of General Dental Checks:

Six Monthly

12 Monthly

Irregular

What are the main concerns about your teeth?

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Find Us

Cannington
Margaret River

address Suites 3 & 4/7-9 Pattie Street,
Cannington
WA 6107, Australia

info@carouselorthodontics.com.au

(08) 9258 8440

Monday:: 8:30am - 5:00pm
Tuesday:: 8:30am - 5:00pm
Wednesday:: 8:30am - 5:00pm
Thursday:: 8:30am - 5:00pm
Friday:: 9:00am - 3:30pm
Saturday:: Closed
Sunday:: Closed

address Suites 12 & 13, The Reef Centre,
33 Fearn Avenue, Margaret River
WA, 6285,

margriverortho@carouselorthodontics.com.au

(08) 9758 8150

Monday:: 9:00am - 5:00pm
Tuesday:: 9:00am - 5:00pm
Wednesday:: 9:00am - 5:00pm
Thursday:: 9:00am - 5:00pm
Friday:: 9:00am - 1:00pm
Saturday:: Closed
Sunday:: Closed

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