New Patient Questionnaire

Patient Name

First Name

Last Name

Date of Birth

Occupation/School

Mobile

Home Phone

Work Phone

Address

Suburb

Postcode

Who recommended you to this practice?

Dentist Name and Suburb

Any other family members who attend this practice

Medical History

Any current medical conditions?

Any allergies?

Are you currently taking any medications?

Dental History

Any heavy falls or blows to the face, or injuries to teeth or jaws?

Any clicking, locking or pain from jaw joints?

Any speech problems or previous speech therapy?

Do you or did you suck your thumb or fingers after the age of 6 years?

Any previous orthodontic treatment or consultation?

What is your reason for attending this practice?

How concerned is the patient for correction of the orthodontic problem?

Additional details if completing for your child

Only complete if different to the answers above

Parent Name

First Name

Last Name

Second Parent Name

First Name

Last Name

Parent Email

Parent Mobile

Parent Home Phone

Parent Work Phone

Parent Address

Parent Suburb

Parent Postcode

How concerned is the parent for correction of the orthodontic problem?

No Referral Necessary