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Holistic Dentistry

Complimentary Holistic and
Biocompatible Dentistry Questionnaire

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Holistic Dentist Brisbane

Holistic Dentistry is an approach that considers a patient’s dental needs alongside their emotions and physical health, promoting total health and well being.

Dr. Kat Marhfour

  • Safe amalgam removal to reduce exposure to the heavy metal neurotoxic mercury vapour
  • Low exposure x-rays using a digital exposure system
  • Limit and avoid toxins from certain dental materials
  • BPA free composite filling material
  • Guidance on a healthy diet to ensure healthy teeth and gums
  • Metal and Mercury detox through diet education
  • Treatment and prevention of gum disease using natural methods

Dr. Marhfour is undergoing further training with ACNEM – Australian College of Nutritional and Environmental Medicine. By undertaking further education, Dr. Marhfour wishes to have a deeper knowledge and understanding of how the body operates holistically as a system and how prevention and healing can be achieved naturally. In Dr. Marhfour’s own personal life, she is very particular about the topic of living an organic, toxin/chemical free lifestyle.

Dr. Don Kelly

  • Safe amalgam removal to reduce exposure to the heavy metal neurotoxic mercury vapour
  • Low exposure x-rays using a digital exposure system
  • Limit and avoid toxins from certain dental materials
  • Neuromuscular testing for TMJ dysfunction using Joint Vibration Analysis and Joint Tracker (JVAJT)

Holistic and Biocompatible Dentistry

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff. 


Holistic Dentistry Questionnaire

Holistic Elements
Other Reason:
Patient Information
Surname:* Title:
Given Name:* Date of Birth:*
Ph (home):* Ph (work):
Mobile Number: E-mail:*
Address:* Suburb:*
Postcode:*
Occupation:

Note: If patient is a minor please note below the name of the parent or guardian completing this form

Surname: Title:
Given Name: Phone:
Dental History

Please tick any dental concerns you have?

If you experience headaches, please note where:
If you experience migraines, please note how often:
How long has this gone on?:
If you experience neckaches, please note how often:
Are you happy with the appearance of your teeth?:
Would you like an explanation about tooth whitening?
How long since your last dental visit?::
Would you describe yourself as a relaxed patient?
Have you seen or are you aware of dental hygienists?
Is there anything about previous dental experiences you want us to know?
Do you have any specific requests?:
Sleep - Assessing the quality of your sleep
Is it easy for you to fall asleep at night?
Do you wake up feeling refreshed?
Do you wake throughout the night?
Sleeping position:
Does your partner snore?
Do you snore?
Would you like an explanation about our snoring appliance?

Are you likely to doze off or fall asleep in the following situations?

Medical History

Have you had or are you suffering from any of these? (please tick)

If you smoke, how many cigarettes a day?:
If you drink coffee, how many a day?:
If you drink soft drink, how many a day?:
Other conditions: :
Approximately when was your last medical check up?:
Are you currently seeing a health professional for any health problems?
Are you taking any medications or supplements? (Please specify)::
Are you allergic to anything? (Please specifiy): :
Amalgam Toxicity Questionnaire

This questionnaire is part of a 1996 US FDA approved study called an Institutional Review Board (IRB) to assess how body burden of mercury is determined, toxicity levels etc. It will serve as a warning/alert to clinicians when patients have scores of ‘yes’ in five or more of the questions. It is recommended that such patients be referred to dentists with special knowledge of safe mercury amalgam removal and replacement.

Have you had mental symptoms such as confusion, forgetfulness?
Has severe depression been a frequent problem?
Has ringing in the ears (tinnitus) been present?
Have you had unusual shakiness (tremors) of your hands or arms or twitching of other muscles?
Do you have ‘brown spots’ or ‘age spots’ under your eyes or elsewhere?
Have you tended to have more colds, flu, and other examples of infectious diseases than ‘normal’?
Have you had food allergies or intolerances?
Have you been to many doctors for your health problems and they have usually said “there is nothing wrong”?
Do you have numbness or burning sensations in your mouth or gums?
Do you have numbness or unexplained tingling in your arms or legs?
Have you developed difficulty in walking (ataxia) over the years?
Do you have ten or more amalgam fillings?
Do you often have a ‘metallic’ taste in your mouth?
Have you ever worked as a painter or in manufacturing/chemical/pesticide/fungicide factories or in pulp/paper mills that used mercury?
Have you worked as a dentist or dental assistant?
Have you ever had Candida or yeast infections (vagina, mouth or GI tract)?
Do you have a lot of bad breath (halitosis) or white tongue (thrush)?
Have you frequently had low basal body temperature (below 97.4 degrees F. / 36.5 degrees C.) over the years?
Do you have problems with constipation?
Do you have heart irregularities or rapid pulse (tachycardia)?
Do you have unexplained arthritis in various joints?
Is it common for you to have a lot of mucus in your stools?
Do you have unidentified chest pains even after ECG, X-ray and heart studies are normal?
Is your sleep poor, or do you have frequent insomnia?
Have you had frequent kidney infections or do you have significant kidney problems?
Are you extremely fatigued much of the time and never seem to have enough energy?
Do you have irritability or dramatic changes in behaviour?
Are you on antidepressants now or have you been in the past?
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

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