I would like to welcome you to my practice. This questionnaire is confidential and filling out this form helps us provide the best possible care and treatment for you. To optimise your treatment time, please complete and submit this form at least one week prior to your appointment.

Please arrive 15 minutes earlier than the scheduled appointment time to allow for pre-treatment administration.

Antibiotics: If your medical practitioner or medical specialist advised you that your medical condition or joint replacement requires antibiotic coverage prior to dental appointments, then they must be taken prior to a periodontal consultation and or treatment. If the antibiotics were not taken as advised then the examination cannot occur.

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Personal Details

First Name*

Last Name*

Preferred Names

Preferred Salutation or Title*

What is your gender?*

Female

Male

Other

Date of Birth*

Day

Month

Year

Do you require an interpreter?*

Yes

If you are deaf, hard of hearing or speech-impaired and need assistance, Please let our friendly team know when booking an appointment. To ensure staff are confident they are effectively communicating with you, we may request that you contact an accredited interpreter to assist with your appointment. If you need assistance locating an interpreter for your appointment https://www.qits.com.au/ may be able to help.

Address*

Street Address City State / Region Postcode

Mobile Number*

Home Phone

Work Phone

Preferred Method of Contact*

Mobile

Home Phone

Work Phone

Best Time to Contact You?*

Are you happy to receive information and confirmations by email?*

Yes

I don't have one

Emergency Contact

Contact Name*

Contact Number*

Referring Dentist

Do you have a referring dentist?*

Yes

I do not have a dentist

Name*

Phone Number*

Practice Name*

Is this your regular dentist?*

Yes

Please provide your regular or last visited dentist's information below.

Name*

Phone Number*

Practice Name*

Health Cover

Do You Have Private Health Cover?*

Yes

If yes, provide name of health fund:*

Dental Studies Waiver

As a dental specialist, I am involved in educational lectures or research, which sometimes require treatment records of my patients. All records such as X-rays and photos are used anonymously.

If the need arises, would you allow your treatment records to be used anonymously?*

Yes

What is the Reason for You Making this Appointment?

What is the reason for you making this appointment?*

Please advise your main concern/reason for this consultation?*

What are you unhappy about with your mouth?*

Have you ever had an upsetting dental experience?*

Yes

Please give details:*

Are you nervous or anxious about dental treatment?*

Yes

Please give details:*

Is there anything else about having dental treatment that you would like me to know?*

Yes

Please enter it here:*

Do you suffer from any of the following problems?

1. Bleeding gums*

Yes

When did you first notice this?*

2. Abscesses / gum swellings*

Yes

When did you first notice this?*

3. Bad taste or bad breath*

Yes

When did you first notice this?*

4. Sensitivity to hot / cold / sweet*

Yes

When did you first notice this?*

5. Food trapping between teeth*

Yes

When did this become noticeable?*

6. Spaces opening up between teeth*

Yes

When did this become noticeable?*

7. Teeth growing longer or the gums shrinking*

Yes

When did this become noticeable?*

8. Do you have any loose teeth?*

Yes

When did this become noticeable?*

9. Staining of teeth*

Yes

When did this become noticeable?*

10. Build-up of calculus / scale / tartar*

Yes

When did this become noticeable?*

11. Has anyone else in your family suffered from or noticed similar problems as asked in questions 1 to 10*

Yes

Which family member/s?*

When did they notice similar problems?*

12. How often have you had a clean by your dentist or hygienist?*

13. When was your last professional clean by a dentist or hygienist?*

14. Have you ever been treated by a Periodontist?*

Yes

Please give details including the name of the Periodontist:*

15. Do you generally attend only when you are aware of problems in your mouth?*

Yes

16. Have you ever had orthodontic treatment?*

Yes

Please give details:*

17. Are you brushing with an electric or manual toothbrush?*

Electric Toothbrush

Manual Toothbrush

18. How often do you brush your teeth?*

19. Do you use anything to clean BETWEEN your teeth?*

Yes

What do you USE to clean between your teeth?*

How OFTEN do you clean between your teeth?*

20. Use of mouth rinse?*

Yes

What type of mouth rinse?*

How OFTEN do you use mouth rinse?*

21. How much water would you consume on an average day?*

22. How much tea, coffee, soft drinks, sports drinks or flavoured drinks would you consume on an average day?*

23. Mouth Ulcers?*

Yes

Frequency*

24. Consistent Dry Mouth?*

Yes

Frequency*

25. Jaw Joint: Discomfort, clicking, locking open?*

Yes

26. Jaw clenching or grinding?*

Yes

27. Do you snore and or mouth breathe?*

Yes

Are you happy with the appearance of your:

Smile, mouth, teeth or gums*

Yes

Ability to eat*

Yes

Do you have all of your teeth?*

Yes

Do you have and or are wearing dentures or plates?*

Yes

When were these first placed?*

Is this the original denture or plate that you are wearing?*

Denture Type*

Partial

Full

Denture Material*

Plastic

Metal

Denture Location*

Upper

Lower

Are you happy with your denture / plates?*

Yes

Do you have crowns or bridges?*

Yes

When were these placed?

Are you happy with your crowns / bridges?*

Yes

Have you had any dental implant placed since your last appointment?*

Yes

Where are they?*

When did you get them?*

Are you happy with them?*

Yes

Who placed them for you?*

What brand are the implants (if known)?

Medical History

Medical Doctor’s Name*

Name of Medical Practice*

Contact Phone Number*

Have you been under the care of a medical doctor during the last 12 months?*

Yes

What for?*

Have you ever been advised to take antibiotics prior to dental appointments?

Yes

Please state when and why you have been advised to take antibiotics.*

Please be aware that if you have been advised to take antibiotics prior to dental appointment, then you must take them prior to a consultation and/or treatment by a periodontist. If not the examination can not occur.

Are you taking any medication, drugs, pills, supplements, herbal remedies or vitamins? (prescription or over the counter)? So that we can take appropriate precautions and avoid drug interactions.*

Yes

Please list any medications that you may be taking:*

Drug Name

Dose

Duration of Treatment

Purpose

To add additional information, please click on the + icon, which will add a new line.

Have you taken any medications in the last ten years in particular Steroids or Bone affecting medications / injections?*

Yes

Medication Details*

Drug Name

Dose

Duration of Treatment

Purpose

To add additional information, please click on the + icon, which will add a new line.

Are you aware of any allergic or adverse reaction to any medical or substance?*

Yes

Please list the medicine or substance:*

Please describe the reaction to that medicine or substance:*

Have you ever had an adverse reaction to local anaesthetic or general anaesthetic?*

Yes

Please explain adverse reaction to local anaesthetic or general anaesthetic*

What is your weight in kilograms? (The doctor uses this information for anesthetic purposes).*

Please record your weight using numbers only.

Do you have or have you ever had any of the following conditions?

Anaemia*

Yes

Arthritis / Rheumatism*

Yes

Please state type of arthritis?*

Artificial Joints (hip, knee, etc)*

Yes

Please list the location and date of the joint replacement:*

Location of Replacement (e.g. hip, knee etc)

Date of Replacement

To add additional information, please click on the + icon, which will add a new line.

Asthma / Hay Fever / Respiratory Conditions*

Yes

Auto-immune disorders*

Yes

If Autoimmune / Immune Disorders please describe?*

Cold Sores / Fever / Blisters*

Yes

Cancer*

Yes

Please list and give dates:*

Type of Cancer

Date of Diagnosis

To add additional information, please click on the + icon, which will add a new line.

Chemotherapy / Radiation Treatment*

Yes

List Chemotherapy or Radiation Treatment*

Treatments

Date of Treatments

To add additional information, please click on the + icon, which will add a new line.

Chronic Cough*

Yes

Emphysema*

Yes

Blood Disorders*

Yes

Please specify what type of blood disorder:*

Blood Borne disease such as Hepatitis B or C or D/HIV/AIDS*

Yes

Please explain your Blood borne disease such as Hepatitis B or C or D or HIV / AIDS*

Bleed easily or have nosebleeds*

Yes

Blood in Urine*

Yes

Bruise Easily*

Yes

Bone disorders*

Yes

Please indicate which condition*

Osteoporosis

Osteopenia

When was your bone disorder first diagnosed?*

Bone Marrow Disorders*

Yes

Please specify the type of bone marrow disorder:*

Ear Problems*

Yes

Please explain your ear problems*

Diabetes*

Yes

Type of Diabetes*

Type 1

Type 2

Please advise of the date of Diabetes diagnosis?*

When was your glycosylated haemoglobin levels tested last?*

What is your glycosylated haemoglobin levels?*

Dry Eyes*

Yes

Depression*

Yes

Dry Mouth*

Yes

Epilepsy or Seizures*

Yes

Fainting or Dizzy Episodes*

Yes

Frequent Colds or Sore Throat*

Yes

Glaucoma*

Yes

Headaches*

Yes

What type and how frequent are the headaches?*

Type of Headache

Frequency of Headache

To add additional information, please click on the + icon, which will add a new line.

Hepatitis A / B*

Yes

Type*

Congenital Heart disease*

Yes

Angina / Heart Pain*

Yes

Rheumatic Fever*

Yes

Heart Murmurs*

Yes

If yes, are these benign or require antibiotic coverage?*

Benign

Require antibiotic coverage

Surgical corrections to heart – heart valve or bypass*

Yes

Please provide details:*

What was the procedure?

When was this performed?

To add additional information, please click on the + icon, which will add a new line.

Mitral Valve Prolapsed*

Yes

What was the date of prolapse?*

Kidney Disease*

Yes

Please state the kidney disease problem*

Liver Disease / Jaundice*

Yes

Please state the liver disease problem?*

Nervous / Anxiety*

Yes

Neurological Disorders*

Yes

Please state the Neurological Disorder*

Reflux / Vomiting*

Yes

Swollen Ankles*

Yes

Stomach Ulcers*

Yes

Please state the stomach ulcer problem?*

Sinus Problems*

Yes

Sudden Weight Change*

Yes

Thyroid Problems*

Yes

If you have thyroid problems, please state what is the problem?*

Tuberculosis / Pneumonia*

Yes

What was the condition?*

Tuberculosis

Pneumonia

When did the condition occur?*

Tumours*

Yes

Please advise the type, location and treatment performed*

Visual Disturbances*

Yes

Please tell us more about your visual problem*

Blood Pressure*

Yes

Please indicate if it is high or low:*

High

Low

Heart Stents*

Yes

When was it placed?*

Haemophillia*

Yes

Type of Haemophillia?

High risk for blood borne disease*

Yes

Do you smoke / vape?*

Yes

Please state what you are smoking / vaping*

How much are you smoking / vaping?*

How long you have been smoking / vaping for?*

Have you ever smoked / vaped?*

Yes

Please state when you ceased smoking / vaping*

Please state duration of smoking / vaping*

Please state daily or weekly smoking / vaping average*

Do you have any proposed surgical operations either medical or dental in the next 12 months?*

Yes

Please detail all proposed surgical operations either medical or dental in the next 12 months*

Any previous operations either medical or dental?*

Yes

Please list all operations and their date:*

Operation

Date of Operation

To add additional information, please click on the + icon, which will add a new line.

Do you have or have had any diseases, conditions or problems not listed?*

Yes

Please provide details:*

Are you or do you think you maybe pregnant?*

Yes

Number of months of pregnancy?*

Have you previously been pregnant?*

Yes

Are you currently breastfeeding?*

Yes

Have you had your Covid-19 vaccination?*

Yes

Please select which vaccinations you have had:

First Dose

Second Dose

Booster

I hereby declare, that all of the information I have provided is complete and correct. I am aware that missing or incomplete information, whether deliberate or the result of negligence, may prevent Dr Bourke from accurately assessing and treating my periodontal status and may cause harm to my overall health.*

Yes

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Today's Date

DD slash MM slash YYYY

By submitting this form you are agreeing to the following terms and conditions:

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider, who may release such information to you. I will notify you of any changes in my health or medication.

To complete the form, you must press the Submit button below.

This field is for validation purposes and should be left unchanged.

Returning Patient

Personal Details

Emergency Contact

Referring Dentist

Health Cover

Dental Studies Waiver

What is the Reason for You Making this Appointment?

Do you suffer from any of the following problems?

Are you happy with the appearance of your:

Medical History

Do you have or have you ever had any of the following conditions?