FIRST NAME
LAST NAME
D.O.B
UNIT / STREET NUMBER
STREET NAME
SUBURB
STATE
NSW
QLD
VIC
NT
SA
TAS
WA
ACT
POSTAL CODE
PHONE
EMAIL
NEXT OF KIN NAME
NEXT OF KIN PHONE NUMBER
HOW DID YOU HEAR ABOUT ANOKHI DENTAL?
From a friend
Existing patient
Social media
Print
Google search
Other
IF YES, FOR WHAT?
DOCTOR / PRACTITIONER NAME
DOCTOR / PRACTITIONER PHONE NUMBER
PLEASE PROVIDE NAMES AND DOSAGES IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE
PLEASE INDICATE WHICH OF THE FOLLOWING YOU HAVE (OR HAVE HAD) AND PROVIDE DETAILS BELOW:
Heart disease (angina, heart attack, dysrhythmia, arrythmia) Congenital heart disease (heart murmur, prolapsed mitral valve) Rheumatic fever/endocarditis Heart surgery Artificial heart valve or pacemaker Stroke High/ low blood pressure Bleeding abnormalities (warfarin therapy, haemophilia) HIV/AIDS Thyroid disease (hyperthyroidism, hypothyroidism, Hashimoto’s thyroiditis, Graves’ disease) Respiratory disease (asthma, bronchitis, emphysema) COVID Tuberculosis Digestive disorders (reflux, leaky gut, Candida, SIBO, constipation) Diabetes Liver disease (jaundice, cirrhosis, fatty liver) Hepatitis Kidney/urogenital/prostate disease Arthritis- rheumatoid/osteo/artificial joints (hip, knee etc) Osteoporosis Psychological disorders (anxiety, depression) Irritability Chronic fatigue Daytime sleepiness Insomnia Unexpected weight gain Sleep apnoea Have you ever had a sleep study? Have you ever seen an Ear, Nose, Throat Specialist (ENT)? Allergies (hay fever, latex) Neurological disorders (epilepsy, dementia, Alzheimer's disease, Parkinson’s disease) Multiple sclerosis Malignancy Chemotherapy Radiotherapy Surgery Do you smoke? Do you consume alcohol? Do you use recreational drugs? None of the above apply to me
PLEASE PROVIDE INFORMATION IF YOU HAVE TICKED "YES" TO ANY OF THE ABOVE OR IF YOU HAVE ANY DISEASE OR CONDITION NOT LISTED:
PLEASE PROVIDE INFORMATION IF YOU HAVE TICKED "YES" TO ANY OF THE ABOVE OR HAVE A CONDITION NOT LISTED:
WHAT IS THE REASON FOR YOUR VISIT?
WHEN DID YOU LAST VISIT A DENTIST?
HOW OFTEN DO YOU HAVE DENTAL CHECK-UPS?
WHEN WAS YOUR LAST PROFESSIONAL DENTAL CLEAN?
WHEN DID YOU LAST HAVE DENTAL X-RAYS?
HOW OFTEN DO YOU BRUSH YOUR TEETH?
HOW OFTEN DO YOU FLOSS?
WHAT ORAL CARE PRODUCTS (TOOTHPASTE, MOUTHWASH, ETC) DO YOU USE?
IF YES, PLEASE DESCRIBE:
TODAY'S DATE
I WOULD LIKE TO RECEIVE EXCLUSIVE UPDATES AND INSIGHTS
Submit
