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New Patient Medical History Form

Medical History Form – Dr Debora Harris (Specialist Orthodontist)

Please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best care for you. All information provided will be kept completely confidential.

Fields marked * are required.

Patient's Information

Title *DrMrMrsMsMissMaster

Patient's First Name*

Patient's Last Name*

Date of Birth*

Patient's Age

Patient's Occupation*

Gender* at BirthMaleFemale

Patient's Phone Number*

Patient's Email*

School (if student)

Patient's Address*

Contact Details

Parent/Carer 1: Full Name (patients under 18 years)

Parent/Carer 1: Phone Number

Parent/Carer 1: Email

Parent/Carer 1: Occupation

Parent/Carer 1: Relationship to child

Parent/Carer 2: Full Name (patients under 18 years)

Parent/Carer 2: Phone Number

Parent/Carer 2: Email

Parent/Carer 2: Occupation

Parent/Carer 2: Relationship to child

Who recommended you to our practice?

Dentist

Dr Name, Practice name and location

Friend

Our Website

Google reviews

Surgery Signage

Facebook / Instagram

Local Sports Club

Sibling

School Newsletter

Other

Health Fund Name / Number?

Has any other member of the family attended our surgery?*YesNo

If yes, Name of family member:

Dental History

Dentist if Different From Above

(Name) Dr:

Practice Name and Location

Date of Last Consult

Have you ever had orthodontic treatment in the past or a previous orthodontic consultation?*YesNo

If yes, please provide details:

What are your main concerns today? Please list all (irregular teeth, appearance, facial profile concerns, jaw pain etc…)

Do you clench/grind your teeth? YesNo

When:

Do you suck your thumb or fingers?YesNo

Have you ever had any jaw/joint problems?YesNo

If yes, please tick the appropriate below;

Inability to open/close jaw?YesNo

Pain?YesNo

Jaw / Joint Noises?YesNo

Jaw / Joint Clicking?YesNo

Jaw / Joint Popping?YesNo

Ringing in Ears?YesNo

Do you snore?YesNo

Have you ever had an ENT assessment?YesNo

Have you ever had a sleep study?YesNo

Do you normally breath through your;Your noseYour mouth

Difficulty sleeping?YesNo

Medical History

Are you currently taking any medications?YesNo

PLEASE LIST ALL MEDICATIONS EVEN IF YOU THINK IT IS NOT RELEVANT TO ORTHODONTICS (please list if you are taking Fosamax or Bisphosphonates)

Have you ever had your tonsils/adenoids removed or consulted an ENT specialist recently?YesNo

If yes, please give details

Do any of the following conditions apply to you?

Heart Problems

Haemophilia

Diabetes

Osteoporosis

Leukemia

Rheumatic Fever

Arthritis

Bone Disorders

Depression

Anxiety

Bipolar disorder

Schizophrenia

Thyroid Problems

Epilepsy

Hepatitis (A)

Hepatitis (B)

Hepatitis (C)

Kidney Disease

Bleeding problems

Asthma

HIV/AIDS

Liver Disease

Sinus problems

ADD/ADHD

Learning Difficulties

Allergies

Hypersensitivity

Sleep apnoea

Autism Spectrum

Other - Please list any other illnesses or conditions or provide details of any of the above conditions.

Patient Acknowledgement

I consent to my orthodontic records being used for education, publishing, or training. The identity and face of patients will not be disclosed.*YesNo

I consent to Specialist Orthodontists Dr. Debora Harris and Associates - Harris Orthodontics - may use encrypted transcription software (such as but not limited to Heidi Health / Lyrebird) during the patient's appointments for the purpose of generating accurate clinical records. I hereby give my informed consent to the use of such software during my appointments at the practice.*YesNo

Permission to take diagnostic records*

By submitting your details and signing below, you:

confirm that the information you have provided is complete and accurate;
confirm you have read, understood and agree to our Privacy Policy which can be accessed here;
confirm that we have your permission to take diagnostic digital records; and refer for diagnostic x-rays.
acknowledge that we may need to correspond with and request records from your previous/ current dentist or specialist to assist with treatment planning, and to correspond with and forward x-rays to specialists as needed. You provide your consent to us taking these steps;
acknowledge that we may need to refer you to other specialists during your treatment;

Patient over 18 years (or Responsible Party) to sign:

Full Name*

Date*

Signature - (Patient / Parent / Guardian)

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Harris Orthodontics

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Harris Orthodontics

Suite 19-21, Level 1
The Exchange Building
1 Elyard Street
Narellan NSW 2567

1800 0 678 46 (1800 0 ORTHO)

reception@harrisortho.com.au

Monday 8:00am - 5:00pm

Tuesday 8:00am - 5:00pm

Wednesday 8:00am - 5:00pm

Thursday 8:00am - 5:00pm

Friday 8:00am - 5:00pm

Saturday Closed

Sunday Closed

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