Medical History Update

An up-to-date medical history is very important for us to continue providing you specialist orthodontic care.

You would have previously submitted a detailed medical history questionnaire for your initial consultation. The purpose of this questionnaire is for you to notify us of any changes to your medical or dental history.

We kindly request that you please provide any updates on your medical history by completing the questionnaire below in advance of your next appointment. Your responses will be kept confidential in accordance with our Privacy Policy

Patient

Date of Birth*:

Patient Contact Details

Please confirm your email and mobile below.

We need to reconfirm your contact details as we communicate important correspondence electronically and want to ensure we have the most up-to-date contact details in our system.

Have any of your other contact details changed? If yes, please complete the details below. If your contact details are unchanged, please leave this section blank.

State:
—Please choose an option—WANSWVICQLDSANTTAS

Do these updated contact details also apply to the Billing Party (the person financially responsible for the account)?*
YesNo

General Dentist

Please confirm your General Dentist below.

We send correspondence relating to your your orthodontic treatment to your General Dentist and so it is important our system reflects the General Dentist you're currently seeing.

Please let us know if you're not currently seeing a General Dentist for ongoing care so that we can provide a recommendation.

Are you seeing any other Specialist Dentists (eg. Prosthodontists, Oral & Maxillofacial Surgeons, Periodontists, Endodontists)?*
YesNo

Are you seeing any other Medical Specialists?*
YesNo

Medical History

Please complete the information below so that we have a current and complete medical history for you.

We appreciate that you may have provided this information previously, however we are of the view that it is prudent to obtain and confirm this information with you on a regular basis so we can stay abreast of any changes that have occurred.

Have you ever had (now or in the past) the following medical conditions?*
YesNo

If yes, please tick all that apply:

ADD 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 orthodontic treatment. It is important that we know precisely what medications (if any) you're currently taking.

Do you currently take, or have you 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

Do you have a substance abuse problem (alcohol, drugs)?*
YesNo

Do you smoke cigarettes (including vaping and e-cigarettes)?*
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

If yes, please tick all that apply:

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

Allergies

Are you allergic to, or have you 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, have you 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 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

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

Specific Conditions / Issues to Highlight

Are there any changes in your medical or dental history that you would like to draw our attention to?

YesNo

Acknowledgement & Consent

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

• I have read all of the questions in the Medical History Update online at www.smilewithconfidence.com.au/updatemhqu18/ 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 Update.

• I confirm that, to the best of my knowledge, the information provided in this Medical History Update is true and accurate and reflects all that is relevant in my treatment.

• 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 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 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.

Please tick this box if you do not consent to your orthodontic records being used for this purpose.

• 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 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 online, I have electronically signed this Medical History Update.