New Patient QuestionnaireStep 1 of 333%Patient's Name First Last Do you have a new patient consultation booked with us?(Required) Yes NoPlease request a new patient appointment at https://thorndonortho.co.nz/contact/Are you completing this form for a child (under 18 years old) or Adult (above 18yrs of age)(Required) Child AdultPatients Name(Required) First Middle Last Patients Name(Required) Dr.MissMr.Mrs.Ms.Mx. Prefix First Middle Last Preferred NameGender(Required) Male Female OtherDate Of Birth(Required) DD slash MM slash YYYY Dentist's Name and/or Practice (or Say "don't have one")(Required)School(Required)OccupationWorkplaceHave you had a dental check in the last year?(Required) Yes NoHow Did You Hear About Us? Google Word of Mouth Treating a Sibling Dentist Recommended Bee Healthy List Other (Please Specify)How Did You Hear About Us? Google Word of Mouth Treating a Sibling Dentist Recommended Bee Healthy List Treating My Child Other (Please Specify)Other, please specify(Required)Who Referred You? Self-Referred I Have a ReferralMain Orthodontic Concern (Yours or Referrers - e.g. Front Teeth Crowded, Crossbite, etc)Parent(s) or Guardian(s)Parent 1's Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Relationship to patient(Required) Mum Dad OtherOther relationship to patientParent 1's Email(Required) Parent 1's Mobile Number(Required)Parent 1's Landline (Home, Work)Parent 1's Address(Required) Street Address Suburb Post Code Is this Parent Soley Responsible for The Account?(Required) Yes NoGuardian 2's Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Guardian 2's Email Guardian 2's Mobile NumberGuardian 2's Landline (Home, Work)Guardian 2's Address Street Address Suburb Post Code Emergency ContactEmergency Contact(Required) First Last Relationship to You(Required)Emergency Contact's Mobile Number(Required)Name of GP (medical practitioner), or medical centre (or say don't have one)(Required)Will You be Responsible For Your Account?(Required) Yes NoYour Address(Required) Street Address Suburb Post Code Guardian's Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Guardian's Email(Required) Guardian's Mobile Number(Required) Guardian's Landline Number Guardian's Address(Required) Street Address Suburb Post Code Medical HistoryGeneral Health (this information ensures we can provide safe and effective treatment and advice)Has the patient had any medical conditions in the past 6 months?(Required) NO Yes (Please Provide Details)Have you had any medical conditions in the past 6 months?(Required) NO Yes (Please Provide Details)Medical Conditions in Past 6 Months(Required)Does the patient take any prescription or non-prescription medication?(Required) No Yes (Please Provide Details)Are you currently taking any prescription or non-prescription medication?(Required) No Yes (Please Provide Details)Medication Details(Required)Have you ever had a significant allergic reaction to anything?(Required) No Yes (Please Provide Details)Has the patient ever had a significant allergic reaction to anything?(Required) No Yes (Please Provide Details)Allergic Reaction DetailsHave you ever received treatment in a hospital or been hospitalised?(Required) No Yes (Please Provide Details)Hospitalised for self(Required)Has the patient ever received treatment in a hospital or been hospitalised?(Required) No Yes (Please Provide Details)Hospitalised for Child(Required)Accidents and TraumaHas the patient had any injuries to the teeth, mouth, jaws or face?(Required) No Yes (Please Provide Details)Have you ever had any injuries to the teeth, mouth, jaws or face?(Required) No Yes (ACC Number and Date of Injury)Acc Injury Date(Required) MM slash DD slash YYYY Injuries Details(Required)Please tick all of the medical conditions below which apply:(Required) NO KNOWN MEDICAL CONDITIONS ADD/ADHD Allergies (including food) Anaemia Arthritis Asthma Autism Spectrum Auto-Immune Bleeding Disorders Bronchitis/Chest Problems Cancer Covid-19 related (long-term) Cold sores Depressive Illness Diabetes (Type 1) Diabetes (Type 2) Eczema Elipsepy Hayfever Headaches or Migraines Heart-Related Conditions Infectious Diseases (HIV, Hep C, etc) Gastric (Stomach) Problems Genetic Conditions Pregnant Snoring, Sleep Apnoea Other (Please Specify)Medical Conditions Details(Required)Declaration(Required) I acknowledge that the information provided above is accurate and true to my knowledge.