7

Your Medical History

Welcome to Mint Dental Mudgeeraba. The following information is requested to enable us to give you our best attention. Each question is relevant to our modern dental practice and is confidential

Personal Information

Address

 Email Phone SMS Post

 First Visit 6 months More than 6 months Health Fund


Medical Information

 Yes No

 Yes No

 Yes

 Yes

 Yes No

 Yes No

Please place a tick beside any of the following you have had:
 Rheumatic Fever Epilepsy Asthma Diabetes Stroke Prosthetic Implant Do you smoke?

 Kidney Disease Excessive Bleeding Heart Complaint High Blood Pressure Anemia Heart Valve Disorder Contact with HIV/AIDS virus

 Tuberculosis Hepatitis Thyroid Disease Nervous Condition Cardiac Pacemaker Any Other Condition

 Yes No Maybe