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New Patient Questionaire (Adults)

All fields marked * are required.

Contact details
First Name*
Surname*
Address
State
Postcode
Home Phone
Mobile Phone
Email*
Date of Birth
Referral Details
Who recommended you to this practice?
Dentist's Name
Dentist's Suburb
Responsible Party's Details
First Name
Surname
Address
State
Postcode
Medical History
List any serious illnesses or allergies
- Asthma
- Fits
- Cleft Lip
- HIV+
- Other
If you selected "Other" please specify here
Are you taking any medication?
- Yes
- No
If yes, what for?
Dental History
Has there ever been a hard knock to, or fracture of, teeth or jaws?
- Yes
- No
Any jaw joint problems or clicks?
- Yes
- No
Have any of the teeth had root canal therapy or very deep fillings?
- Yes
- No
Orthodontics
In your own words, describe the problem with the jaws or teeth as you see it :
What is your concern for correction of the orthodontic problem:
- Very Concerned
- Concerned
- Indifferent
- Opposed
Do you have any particular mouth habits or play a wind instrument?
Are you a mouthbreather?
- Yes
- No
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