*Date

 

*Patient name

 

*DOB

*Sexe

Female

Male

* #ssh

*Adresse

*City

*Zip code

Home Phone

 

Cell Phone

 

Work Phone

*E-mail

Current Insurance

Subscriber #

Subscriber DOB

 

Emergency Contact

Relationship

Home/Cellphone

 

Do you have any of those diseases or problems:

Active Tuberculosis

Yes

No

Persistent cough greater than 3 week duration

Yes

No

Cough that produce blood

Yes

No

Been exposed to anyone with tuberculosis

Yes

No

Dental information

 

 

Do your gum bleed when your brush or fross

Yes

No

Are you teeth sensitive to cold , hot , sweet or pressure ?

Yes

No

Does food catch between your teeth ?

Yes

No

Is your mouth dry?

Yes

No

Have you had any periodontal (gum) treatments ?

Yes

No

Have you had any problemes associated with previous dental treatments?

Yes

No

Do you have any clicking ,poping or discomfort in the jaw ?

Yes

No

Do you brux or grind your teeth ?

Yes

No

Are you currently experiencing dental pain or disconfort ?

Yes

No

What is the reason of your dental visit today ?

Date of your last dental exam ?

Date of your last x-rays: ?

Medical Information

Are you under the care of a physician ?

Yes

No

Physician Name

Phone

Date of your last dental exam ?

Date of your last x rays

Have you had a serious illness , operation or been hospitalized in the past 5 years ?

Yes

No

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes

No

Please mark if you are allergic to any of the following

 

Aspirin

 

Penicillin or other antibiotics

 

Sulfa drugs

 

Codiene or other narcotics

 

Local anesthetics

 

Latex

 

Metals

 

Other

 

 

Please indicate if you have or had any of the following diseases or problems

 

Angina

 

Arteriosclerosis

 

Congestive heart failure

 

Heart attack

 

Heart murmur

 

Low blood pressure

 

High blood pressure

 

Mitral valve prolapse

 

Pacemaker

 

Seizures

 

Fainting Spells

 

Rheumatic fever

 

Rheumatic heart disease

 

Abnormal bleeding

 

Hemophilia

 

 

AIDS or HIV infection

 

Arthritis

 

Autoimmune disease

 

Respiratory problems

 

Asthma

 

Tuberculosis

 

Cancer/Chemotherapy/Radiation Treatment

 

Diabetes Type I or Type II

 

Swollen neck glands

 

Kidney disease

 

Hepatitis, jaundice or liver disease

 

Nervous problems

 

Psychiatric care

 

Taking Coumadin

 

Gastrointestinal disease

 

Sleep disorder

 

Woman Are you pregnant?

Yes

No

if Yes, indicate due date

Is Antibiotic pre-medication necessary due to any heart condition or artificial joint?

Yes

No

List any changes in your medical/detal history:

List all medications you are currently taking: