Anglesea OMS Limited » Health History Form

Patient Health History Questionnaire

Patient Information

First name

Surname

Date of birth (dd/mm/yyyy)

Weight (kg)

Height (cm)

Address

Home Phone

Work Phone

Mobile Phone

Fax

Name of referring Dentist?

Name of family Doctor?

Name of Company & Policy

Date of accident (dd/mm/yyyy)

Claim number

Please specify specialist card/bracelet details

Have you had any of the following?

What? (specify details)

When? (dd/mm/yyyy)

What? (specify details)

When? (dd/mm/yyyy)

What? (specify details)

When? (dd/mm/yyyy)

What? (specify details)

When? (dd/mm/yyyy)

Please provide more details

What? (specify details)

When? (dd/mm/yyyy)

What? (specify details)

How often?

Specify how many per day

Specify when (dd/mm/yyyy)

Specify how many per day

(Penicillin or other antibiotic, aspirin or other tablets) Please specify

Please specify

Please specify type

Please provide more details

Questions for Female Patients

How many months?

What type of pill?

Next of kin details

First Name

Surname

Relationship (i.e. Mother/Father)

Address

Home Phone

Work Phone

Mobile Phone

Fax

Details of the Parent/Guardian/Caregiver if patient is UNDER 16 YEARS OF AGE

First Name

Surname

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Due to Covid 19 and the rise alert level 4 Anglesea OMS is closed until further notice.

If is an emergency situation, please email reception@anglcoms.co.nz and we will do our best to assist you.

Dental Council and the Ministry of Health advises all non-essential and elective dental services, particularly those generating aerosol, should be suspended immediately to reduce the risk of community spread, including to yourself, your staff and your patients.

Sorry for any inconvenience caused.

Patient Health History Questionnaire

Patient Information

Have you had any of the following?

Questions for Female Patients

Next of kin details

Details of the Parent/Guardian/Caregiver if patient is UNDER 16 YEARS OF AGE

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Address:

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