Medical and Dental Questionnaire

New Patients

Your answers are confidential and are essential for a complete orthodontic evaluation. Our practice uses Heidi Health which is a medical AI notetaker that complies with Australian Privacy Regulations. This allows us to concentrate on providing excellent care to you. All the information Heidi gathers is deleted at the end of the day and cannot be linked back to you. If you would like to discuss this with us prior to your appointment please contact us.

New Patient Questionnaire
(if under 18 years)

Please answer YES/NO to indicate whether you/the patient has any of the following conditions

Medical Questionnaire

Heart problems
Allergy to any medications, food, or jewelery
High or low blood pressure
Bleeding disorder
Asthma, sinusitis or hay fever
Are you taking any medications?
Epilepsy, seizures or fainting
Diabetes
Liver or kidney disease
Stroke
Have you been hospitalised in the past 2 years?
Arthritis
Stomach ulcers or reflux
Thyroid or endocrine problems
Physical disability
Depression or anxiety
Alcohol or substance dependance
Chemotherapy or radiotherapy
Tuberculosis
Adenoids or tonsils removed
Trauma to head or face
Do you/the patient smoke?
Might you/the patient be pregnant?
Do you/the patient use recreational drugs?
Do you have an other disease or health condition not listed above?

For Parents of Children

If your child is female, have they started their period?
Does your child struggle to breathe when they sleep?
Does your child snore?
Does your child have any developmental delays or impairments?
Does your child have any behavioural issues?
Does your child suck their thumb?

Dental Questionnaire

Have you/the patient had any orthodontic treatment in the past?
Do you consent for us to correspond with your dentist about your treatment?
Are you aware of any dental treatment which needs to be completed?
Do you ever notice clicking, locking or pain in your jaw joints?
Have you ever had any teeth extracted at the dentist?

Declaration

I have read the above form and I have provided answers to the best of my knowledge. If there are any changes to my/ my child’s medical or dental history I will inform the Practice as soon as possible. I have also had an opportunity to read and agree to the Practice Privacy Policy.

Australian Dental Association
Australian Society of Orthodontists
Australasian Orthodontic Board
Newcastle Orthodontics

Operating Hours

Monday - Friday
8.00am - 5.00pm

Contact Us

(02) 4942 3769
reception@newcastleorthodontics.com.au
Suite c102, 215-217 Pacific Highway,
Charlestown 2290

Book an Appointment

Located in the heart of Charlestown, 15 minutes South of Newcastle, NSW, Australia.