Claremont | 08 9384 6855 Jandakot | 08 9414 1470

Medical History Questionnaire

    We look forward to welcoming you and your child 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

    Patient Details

    Title*:

    Date of Birth*:

    Gender*:

    State*:

    Does your child play a musical instrument?
    YesNo

    Parent/Guardian Details

    Parent/Guardian 1

    Relation to Patient*:

    Title*:

    Please complete the contact information below if different to the Patient details. If Parent/Guardian contact details are the same as the Patient contact details, please leave blank.

    State:

    Parent/Guardian 2

    Relation to Patient:

    Title:

    Please complete the contact information below if different to the Patient details. If Parent/Guardian contact details are the same as the Patient contact details, please leave blank.

    State:

    Billing Party (the person who is responsible for paying the Patient financial account)

    Who will be the Billing Party for the Patient’s account?*:

    Please complete the contact information below if the Billing Party is NOT the Parent/Guardian1 or Parent/Guardian2:

    Title:

    State:

    Family Structure

    Who does the Patient live with? (select all that apply)
    MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianOther

    Who will be bringing the Patient to appointments? (select all that apply)
    MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianBabysitterNannyAu pairOther

    Does the Patient have any siblings?
    YesNo

    Sibling 1 First Name:

    Sibling 1 Age:

    Current patient of Dr Siva's?
    YesNo

    Sibling 2 First Name:

    Sibling 2 Age:

    Current patient of Dr Siva's?
    YesNo

    Sibling 3 First Name:

    Sibling 3 Age:

    Current patient of Dr Siva's?
    YesNo

    Sibling 4 First Name:

    Sibling 4 Age:

    Current patient of Dr Siva's?
    YesNo

    How did you hear about us?

    General Dentist

    Does your child see a General Dentist for their regular dental care?*
    YesNo

    Has your child ever seen a Specialist Paediatric Dentist?*
    YesNo

    Has your child ever seen any other Specialist Dentists (eg. Prosthodontists, Oral & Maxillofacial Surgeons, Periodontists)?*
    YesNo

    General Practitioner (GP or Doctor)

    Does your child see a General Practitioner (GP or Doctor) for their regular medical care?*
    YesNo

    Is your child seeing any other Medical Specialists?
    YesNo

    Background for the Initial Orthodontic Consultation

    Has your child had orthodontic treatment previously?*
    YesNo

    Are you seeking a second opinion for your child’s orthodontic treatment plan?*
    YesNo

    There are some orthodontic conditions that run in families (eg. missing teeth, narrow upper jaws, underbites) and so it is helpful to understand the orthodontic history of your child’s immediate and extended family.

    Have any of your child’s siblings (brothers/sisters) had orthodontic treatment?*
    YesNo

    Have any of your child’s parents had orthodontic treatment?*
    YesNo

    Have any of your child’s extended family members (aunts/uncles/cousins/grandparents) had orthodontic treatment?*
    YesNo

    Medical History

    Has your child 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

    Does your child snore?*
    YesNo

    Has your child had their tonsils and/or adenoids removed?*
    YesNo

    Has your child been diagnosed with, or could they have, sleep apnea?*
    YesNo

    Medications/Lifestyle

    Some medicines may interfere with your child’s orthodontic treatment. It is important that we know precisely what medications (if any) which your child is taking.

    Does your child take, or has been taking recently, any of the following medications?*
    YesNo

    If yes, please tick all that apply:

    AspirinWarfarin or Heparin (or other blood thinners)Oral contraceptive (the Pill)Cortisone or steroidsMedication for depression or anxietyTreatment for osteoporosis (Bisphosphates, Prolia)Hormone supplementsFluoride supplementsOther prescription medicationsHerbal or naturopathic medicationsNutritional supplementsOver-the-counter medications

    If you have ticked any of the medications above, please provide dose and frequency

    Could your child have a substance abuse problem (alcohol, drugs)?*
    YesNo

    Could your child smoke cigarettes (including vaping and e-cigarettes)?*
    YesNo

    Family History

    Does your child have any birth defects or hereditary problems?*
    YesNo

    Does your child’s siblings and/or parents have any of the following health problems?*
    YesNo

    If yes, please tick all that apply:

    Bleeding disordersDiabetesArthritisSevere allergiesMissing teethExtra teethJaw size imbalanceProminent lower jaw (underbite)Recessive lower jawUnusual dental problems

    Does your child have any other medical conditions that we should be aware of?*
    YesNo

    Allergies

    Is your child allergic to, or has had an allergic reaction, to any of the following?*
    YesNo

    If yes, please tick all that apply:

    Local anaesthetics eg. novocaine, lidocaine, xylocaineIbuprofen eg. Nurofen, AdvilAspirinPenicillinOther antibioticsMetals eg. jewellery, clothing snapsLatex eg. gloves, balloonsAcrylicsAnimalsFoodsPlant pollensOther allergies

    Dental History

    Now or in the past, has your child had any of the following?*
    YesNo

    If yes, please tick all that apply:

    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 does your child brush their teeth?*

    Does your child wear a mouthguard when playing sport?*
    YesNoNot Required

    Do you think any of your child’s activities affect their face, teeth or jaws?
    YesNo

    Have you noticed any unusual changes in your child’s face or jaws?
    YesNo

    Does your child have any other dental history we should be aware of?
    YesNo

    Acknowledgement & Consent

    By electronically clicking SUBMIT on this Medical History Questionnaire, I hereby certify:

    • I have read all of the above questions 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 the treatment of my child for orthodontics.
    • I will notify Orthodontics on St Quentin or Orthodontics on Berrigan (as relevant) of any changes in my child’s medical or dental health as soon as reasonably practicable.
    • I consent to the performance of a comprehensive clinical examination and assessment of my child for 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 child’s personal and dental records to other dental and medical practitioners involved in my child’s care.
    • I consent to the use and publication of my child’s 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.
      Please tick this box if you do not consent to your child’s orthodontic records being used for this purpose.
    • I am aware Orthodontics on St Quentin and Orthodontics on Berrigan have a Privacy policy which I can access here. I understand the reasons why our 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 your account may be sent to debt-collector with the costs associated with debt recovery charged to your account. Payment of fees for orthodontic treatment will be subject to a separate financial agreement.
    • I understand and agree that by clicking SUBMIT I am electronically signing this online Medical History Questionnaire