Best wishes for the holiday season! Our clinics will be closed from 24th December and will reopen on 2nd January, 2026. Please email us with any enquiries during this period. For existing patients with urgent problems, send text message and photo of the problem to 0439 782 180.

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(08) 9258 8440

(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)

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

Medical And Dental History (Adults)

Patient details

All fields must be completed

Patient First Name*

Patient Last Name*

Gender

Male

Female

Not Listed

If not listed, please give preferred gender identification

Preferred Pronoun

He

She

They

Other

If other, please give preferred pronoun

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

No

*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

No

If yes, please describe

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

Yes

No

If yes, please list

Are you currently taking any regular medications?

Yes

No

If yes, please list

Are you Allergic to anything?

Yes

No

If yes, please list

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

Yes

No

If yes, please describe

Have you had any psychological or nervous disorders?

Yes

No

If yes, please describe

Do you smoke cigarettes?

Yes

No

Do you consider yourself to currently be in good health?

Yes

No

Is there a chance you may be pregnant?

Yes

No

If YES, how many months

Do you have any of the following health issues

ADD/ADHD

Yes

No

Diabetes

Yes

No

Asthma

Yes

No

Epilepsy

Yes

No

Autism/Aspergers

Yes

No

Heart or Blood Pressure Problems

Yes

No

Blood/Bleeding Disorders

Yes

No

Hepatitis B/HIV

Yes

No

Cleft Lip or Palate

Yes

No

Kidney or Liver problems

Yes

No

Congential Birth Defects/Syndromes

Yes

No

Osteoporosis

Yes

No

Depression

Yes

No

Speech or Hearing problems

Yes

No

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

Yes

No

If yes, please describe

Dental History - Have you had any of the following?

Chronic Mouth breathing

Yes

No

Jaw Joint (TMJ) clicking or locking

Yes

No

Clenching or Grinding of Teeth

Yes

No

Oral Habits

Yes

No

Dental or Facial Trauma

Yes

No

Previous Orthodontic Treatment

Yes

No

Frequent Mouth Ulcers

Yes

No

Tooth Decay or Fillings

Yes

No

Gum Disease

Yes

No

Wisdom tooth extractions

Yes

No

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

Yes

No

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

Opening Hours

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

Opening Hours

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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