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Please complete this personal health history form to the best of your ability. Have your list of medications ready. It will help your consulting dentist give you the best help fast. Thanx!
15
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1
Name
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Prefix
First Name
Last Name
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2
Date of Birth
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Date
Year
Month
Day
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3
Residential Address
*
This field is required.
This is a legal requirement to write prescriptions and other diagnostic referrals
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Best contact phone number
*
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In case we can't connect with you via video. Mobile is preferred - please put the first 4 digits into the area code section
Area Code
Phone Number
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5
Best personal email
*
This field is required.
To send your report and other oral health resources
example@example.com
Confirm Email
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6
Please list your private health insurer for dental if you have one
E.g. HCF, NIB, Medibank Private etc. Please leave this answer box empty if you don't have dental insurance
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7
Are you experiencing any pain, swelling or bleeding from inside or around your mouth, jaws or face?
Please select the best answer for your current dental situation below
I have NO pain, swelling or bleeding
I have PAIN only
I have pain AND swelling or bleeding
I have bleeding or swelling but NO pain
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8
How severe is your pain?
From "it's the worst pain ever!" (sad face) on the far left to "no pain" (happy face) on the far right
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
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9
Do you have any broken, loose or discoloured teeth?
Please select the best answer for your current dental situation below
No I don't
Yes I have a recently broken, loose or discoloured tooth that can be seen with smiling or talking
Yes I have a recently broken, loose or discoloured tooth that cannot be seen but I can feel it and it's annoying me
Yes, its been broken, loose or discoloured for some time now. I can live with it, but I know I should get something done about it
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10
We're pleased to hear you have no broken, loose or discoloured teeth, no pain, swelling or bleeding from your mouth or face. Please share your reason for wanting an online dental consult:
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11
When did you last see a dental practitioner in person?
Less than six (6) months ago
Less than a year ago
More than a year ago
More than five (5) years ago
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12
Please upload your current list of medications and supplements
Supported file formats are pdf, doc, docx, xls, xlsx, csv, jpg, jpeg, png, or gif. Max file size is 10MB. Up to 5 files can be uploaded. **** You can take a photo of your list in the next question if preferable - leave this question blank ****If you don't have a ready list to upload you can type your medications in the question after next - leave this and the next question blank.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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13
Take a photo of your list of medications and supplements
If you haven't already uploaded a document in the previous question. If you prefer to type in your medications click to the next question
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14
Please list your current medications and supplements by brand or generic name and dosage
E.G Blood pressure medication - Cartia (Diltiazem) 240mg 1x daily
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15
Are you experiencing any of the following health conditions?
Please tick all that apply
Heart, cardiovascular or blood condition
Respiratory or breathing condition
Allergies
Immune deficiencies
Had an operation in the past
Metabolic conditions eg diabetes
Prosthetic implants or joints
Cancer or malignancies
Infectious disease eg HIV, tubercolosis, flu, etc
IVF therapy, pregnant or lactating
Been admitted to hospital in the past 2 years for any reason other than childbirth
Other
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16
Please tell us more about your health condition(s):
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17
Have you ever been advised to take prophylactic antibiotics before dental treatment?
YES
NO
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18
Have you ever taken bisphosphonate medication for bone conditions such as osteoporosis?
YES
NO
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19
Receiving ViDe oral health advice and concierge services on the basis of the information you provided in this personal history form is subject to terms and conditions. If you do not agree, please do not continue to use the ViDe platform
*
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Please read the ViDe purchase terms and conditions via the link below
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20
Please sign to confirm all the personal health details you've entered on this form are correct and up-to-date
Please use the mouse cursor, your finger or a tablet stylus
Clear
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21
Tags
Todo
In Progress
Done
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