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Caroline Springs (03) 9363 6300

Broadmeadows (03) 9309 5699

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Medical History Update form

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Personal information

Full Name*

Date of Birth*

Address*

Phone Number*

E-mail*

Date of last visit

Health Information

Do you suffer from:

Heart/Vascular Disorder

Blood Disease/Bleeder

Blood Pressure Problem

Rheumatic Fever

Arthritis

Diabetes

Liver or Kidney Disease

Asthma

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General Health Updates

Since your last visit, have there been any changes in your general health?* Yes No

If yes, explain

Have you had any recent hospitalizations or surgeries?* Yes No

Have you had diagnosed with any new medical conditions?* Yes No

Have you had any recent illness (cold, flu, infections)? Yes No

Is there a possibility that you could be pregnant? Yes No

Dental/Orthodontic Concerns

Have you had any pain, discomfort, or sensitivity? * Yes No

Have you had any problems with appliances (braces, aligners, retainers)? * Yes No

Have you seen a general dentist or other dental specialists since your last visit? * Yes No

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Caroline Springs
Broadmeadows

Caroline Springs

Clear Orthodontics Suite 3, 240 Caroline Spring Blvd,
Caroline Springs
VIC 3023

Clear Orthodontics (03) 9363 6300

reception@clearorthodontics.com.au

Opening Times

Monday: 8am - 5pm
Tuesday: 8am - 5pm
Wednesday: 8am - 5pm
Thursday: 8am - 5pm
Friday: 8am - 5pm
Saturday: Closed
Sunday: Closed

Clear Orthodontics Free Parking

Clear Orthodontics Easy Access

Clear Orthodontics Open in Google Maps

Broadmeadows

Clear Orthodontics Shop 3, 11-17, Pearcedale Parade,
Broadmeadows
VIC 3047

Clear Orthodontics (03) 9309 5699

reception@clearorthodontics.com.au

Opening Times

Monday: 8am - 5pm
Tuesday: 8am - 5pm
Wednesday: 8am - 5pm
Thursday: 8am - 5pm
Friday: 8am - 5pm
Saturday: Closed
Sunday: Closed

Clear Orthodontics Free Parking

Clear Orthodontics Easy Access

Clear Orthodontics Open in Google Maps

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