We look forward to welcoming you to our specialist orthodontic clinic.
We kindly request that you please provide the following information in advance of your initial consultation with Dr Siva. A thorough and complete medical and dental history is very important for a specialist orthodontic consultation. Your responses will be kept confidential in accordance with our Privacy Policy
Title*: —Please choose an option—MasterMissOther
Date of Birth*:
Gender*: —Please choose an option—FemaleMaleNon-Binary
State*: —Please choose an option—WANSWVICQLDSANTTAS
Do you play sport or engage in other physical activity?* YesNo
Do you play a musical instrument? YesNo
Relation to Patient*: —Please choose an option—WifeHusbandPartnerDefactoBoyfriendGirlfriendMotherFatherGrandparentSisterBrotherAuntUncleGodparentGuardianOther
Title*: —Please choose an option—MrsMrMsDrDeceasedOther
Please complete the contact information below if different to the Patient details. If Partner/Relative/Next of Kin contact details are the same as the Patient contact details, please leave blank.
State: —Please choose an option—WANSWVICQLDSANTTAS
Who will be the Billing Party for the Patient’s account?*: PatientPartner/Relative/Next of KinOther Person
Please complete the contact information below if the Billing Party is NOT the Patient or Partner / Relative / Next of Kin:
Title: —Please choose an option—MrsMrMsDrDeceasedOther
Relationship Status: —Please choose an option—SingleEngagedMarriedDefactoSeparatedDivorcedIn a relationshipPrefer not to say
Do you have a partner? YesNo
Do you have any children? YesNo
Child 1 First Name:
Child 1 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Current patient of Dr Siva's? YesNo
Child 2 First Name:
Child 2 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Child 3 First Name:
Child 3 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Child 4 First Name:
Child 4 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Referred by General Dentist
Referred by another Practitioner
A family member comes here
A friend comes here
Google Search/Website
Facebook
Instagram
Drove / walked past the practice
Recommended by someone else
Do you see a Dental Practitioner for your regular dental care?* YesNo
Have you ever seen any other Specialist Dentists (eg. Prosthodontists, Oral & Maxillofacial Surgeons, Periodontists)?* YesNo
Do you see a General Practitioner (GP or Doctor) for your regular medical care?* YesNo
Are you seeing any other Medical Specialists? YesNo
Have you had orthodontic treatment previously?* YesNo
Are you seeking a second opinion for your orthodontic treatment plan?* YesNo
What would you like to change about your teeth?*
Straighten the upper front teethStraighten the lower front teethStraighten the upper back teethStraighten the lower back teethMake the upper front teeth longerMake the upper front teeth shorterMove the upper teeth forwardMove the upper teeth backwardMove the lower teeth forwardMove the lower teeth backwardMake the line of the upper front teeth more levelMove the midline of the upper teeth to the leftMove the midline of the upper teeth to the rightMove the midline of the lower teeth to the leftMove the midline of the lower teeth to the rightChange something else about my teethI don't want to change anything about my teeth
If your facial appearance could be changed, what would you change?*
Get rid of the sag under my lower jawMove my chin forwardMove my chin backwardMove my chin to the left to centre itMove my chin to the right to centre itMove my lower lip forwardMove my lower lip backwardMove my upper lip forwardMove my upper lip backwardMove the area around my nose forwardMove the area around my nose backwardMake the profile of my nose longerMake the profile of my nose shorterMove the area under my eyes forwardMove the area under my eyes backwardMake my cheekbones largerMake my cheekbones smallerShow more of my teeth when I smileShow less of my teeth when I smileShow more of my gums when I smileShow less of my gums when I smileMake my lips closer together when I smileMake my lips further apart when I smileMake my lips closer together when my teeth are touchingMake my lips further apart when my teeth are touchingMake my lips not touch and roll out when my teeth are touchingReduce the strain in my chin when I close my lipsReduce the strain in my lips when I close themMake my face more narrowMake my face more wideReduce the width of my lower jaw behind my mouthReduce the fullness of my lower jaw behind my mouthI don't want to change anything about my facial appearanceChange something else about my facial appearance
Do you experience any pain or discomfort in your jaw (eg. TMJ) or the muscles around your jaw?* YesNo
If yes, please select where the location of the pain/discomfort is
In front of my right earIn front of my left earAbove my right earAbove my left earBelow my right earBelow my left earIn my right earIn my left ear
Are you seeing a Dental or Medical Specialist for jaw joint pain or discomfort? YesNo
Do you experience any of the following symptoms?* YesNo
Daytime sleepiness of fatigueNight time snoringNight time wakingInsomniaIncreased blood pressure or irregular heartbeatDepression
Have you been diagnosed with obstructive sleep apnea?* YesNo
There are some orthodontic conditions that are more genetically prevalent in families (eg. missing teeth, narrow upper jaws, underbites) and so it is very helpful to be provided with the orthodontic history of your immediate and extended family.
Have any of your siblings (brothers/sisters) had orthodontic treatment?* YesNo
Have any of your parents had orthodontic treatment?* YesNo
Have any of your extended family members (aunts/uncles/cousins/grandparents) had orthodontic treatment?* YesNo
Have you ever had (now or in the past) the following medical conditions?* YesNo
If yes, please tick all that apply:
Premature birthDifficult birthTwinBehavioural problemsADD or ADHDAutism spectrum disorderOther developmental disorderSensory sensitivitiesCommunication difficultiesSpeech therapyIntellectual disabilityPhysical disabilityTraumatic medical experienceEating disorder eg. anorexia or bulimiaAnxietyDepressionOther mental health disturbancesFrequent headaches or migrainesSeizuresEpilepsy (fits)Fainting spellsMultiple sclerosisCerebral palsyNervous system disorderOther neurological issuesChest pain or shortness of breathTire easilyHigh or low blood pressureRheumatic feverCongenital heart defectHeart murmurRheumatic heart diseaseAnginaArteriosclerosisStrokeHeart attackCardiac pacemakerHeart valve replacementAny other heart (cardiac) issueAsthmaBronchitisPneumoniaCystic fibrosisRespiratory diseaseOther lung conditionsCancer or a tumorChemotherapy or radiation therapyTransplanted organBone marrow or stem cell transplantInjuries to the face, head or neckBone fractureJoint replacement surgeryArthritisLow bone densityOsteoporosisVision issue (including wearing glasses)Eye surgeryDeaf or hearing issueRecurrent ear infectionsTonsil or adenoid conditionHayfeverSinus problemsDiabetes or low blood sugarEndocrine or thyroid problemsThyroid problems (including goiter)Gastroesophageal reflux disease (GORD)Inflammatory bowel diseaseFamily history of diabetesUrinary tract infectionsKidney diseaseImmunocompromisedAutoimmune diseaseEczemaSkin disorders (other than common acne)Extensive burnsExcessive bleedingExcessive bruisingAnaemiaBlood disorderHepatitisJaundice or liver diseaseTuberculosisPolioMononucleosisGonorrhoea, syphilis, herpes or other sexually transmitted diseasesAIDS or HIVOther infectious disease
Sleep & Breathing
Do you snore?* YesNo
Have you had your tonsils and/or adenoids removed?* YesNo
Have you been diagnosed with, or could you have, sleep apnea?* YesNo
Medications/Lifestyle
Some medicines may interfere with your orthodontic treatment. It is important that we know precisely what medications (if any) which you are taking.
Do you take, or have you been taking recently, any of the following medications?* YesNo
AspirinWarfarin or Heparin (or other blood thinners)Oral contraceptive (the Pill)Cortisone or steroidsAntidepressants or medication for depression or anxietyHormone supplementsFluoride supplementsOther prescription medicationsHerbal or naturopathic medicationsNutritional supplementsOver-the-counter medications
Have you ever taken intravenous bisphosphates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etridonate) for bone disorders or cancer? YesNo
Have you ever taken oral bisphosphates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiluronate) or Didronel (etidronate) for bone disorders? YesNo
If you have ticked any of the medications above, please provide dose and frequency
Do you or have you ever had a substance abuse problem (alcohol, drugs)?* YesNo
Do you smoke cigarettes or have you smoked in the past (including vaping and e-cigarettes)?* YesNo
Do you eat a well balanced diet?* YesNo
Are you or could you be pregnant?* YesNo
Family History
Do you have any birth defects or hereditary problems?* YesNo
Do your siblings and/or parents have any of the following health problems?* YesNo
Bleeding disordersDiabetesArthritisSevere allergiesMissing teethExtra teethJaw size imbalanceProminent lower jaw (underbite)Recessive lower jawUnusual dental problems
Do you have any other medical conditions that we should be aware of?* YesNo
Are you allergic to, or have you had an allergic reaction, to any of the following?* YesNo
Local anaesthetics eg. novocaine, lidocaine, xylocaineIbuprofen eg. Nurofen, AdvilAspirinPenicillinOther antibioticsMetals eg. jewellery, clothing snapsLatex eg. gloves, balloonsAcrylicsAnimalsFoodsPlant pollensOther allergies
Now or in the past, have you had any of the following?* YesNo
Teeth erupting earlyTeeth erupting latePrimary (baby) teeth removed that were not loose or ready to fall out naturallyPermanent teeth removedExtra (supernumerary) teeth removedLost or broken fillingsDental injury or dental traumaTeeth causing irritation to the lips, cheeks or gumsTeeth treated with root canals or pulpotomiesCysts in the mouth/jaw regionJaw fracturesTraumatic dental experienceFrequent canker sores or cold soresSensitive or sore teethSoreness in jaw muscles or facial musclesTooth grinding or clenchingTMJ or TMD problemsClick or locking jaw jointsPacifier (dummy) useFinger suckingThumb suckingPen chewingOral sensitivities
How often do you brush your teeth?* —Please choose an option—Twice DailyDailyWeeklyOccasionallyUnsure
Do you wear a mouthguard when playing sport?* YesNoNot Required
Do you think any of your activities affect your face, teeth or jaws? YesNo
Have you noticed any unusual changes in your face or jaws? YesNo
Do you have any other dental history we should be aware of? YesNo
By electronically clicking SUBMIT on this Medical History Questionnaire, I hereby certify:
I have read all of the questions in the Medical History Questionnaire online at www.smilewithconfidence.com.au/mhqu18/ and will not hold Dr Sivabalan Vasudavan, Orthodontics on St Quentin or Orthodontics on Berrigan responsible for any errors or omissions which I have made in the completion of this Medical History Questionnaire.
I confirm that, to the best of my knowledge, the information provided in this Medical History Questionnaire is true and accurate and reflects all that is relevant in my treatment for orthodontics.
I will notify Orthodontics on St Quentin or Orthodontics on Berrigan (as relevant) of any changes in my medical or dental health as soon as reasonably practicable.
I consent to the performance of a comprehensive clinical examination and assessment of my orthodontic treatment including the procurement of diagnostic records such as digital photographs, digital radiographs and digital study model scans.
I consent to the sharing and release of my personal and dental records to other dental and medical practitioners involved in my care.
I consent to the use and publication of my dental records (including photographs, radiographs and videos) made in the course of examinations, treatment and review for purposes of professional consultations, research, education, publication in professional journals and for marketing purposes including social media.
I DO NOT consent to the use and publication of my dental records (including photographs, radiographs and videos) made in the course of examinations, treatment and review for purposes of professional consultations, research, education, publication in professional journals and for marketing purposes including social media.
I am aware Orthodontics on St Quentin and Orthodontics on Berrigan have a Privacy Policy which is located at www.smilewithconfidence.com.au/privacy-policy/. I understand the reasons why my personal information must be collected and hereby consent to the handling of our personal information by Orthodontics on St Quentin, Orthodontics on Berrigan and Dr Sivabalan Vasudavan in accordance with this Privacy Policy.
I understand payment for fees for consultations and diagnostics records will be required on the day of the appointment. Non-payment of my account may be sent to debt-collector with the costs associated with debt recovery charged to my account. Payment of fees for orthodontic treatment will be subject to a separate financial agreement.
I understand and agree that by clicking SUBMIT online, I have electronically signed this Medical History Questionnaire.
