Dr's. Allen and Harris - Patient Forms

Form: Medical and Dental History

Patient Information

FIRST Name

LAST Name

Name of patients physician and their specialty:

Most recent physical examination:

What is the estimate of your general health? (excellent/good/fair/poor)

DO YOU HAVE or HAVE YOU EVER HAD:

1. Hospitalization for illness or injury

YES

2. An allergic or bad reaction to any of the following:

Please choose YES or NO for all questions below.

aspirin, ibuprofen, acetaminophen, codin

YES

penicillin

YES

erythromycin

YES

tetracycline

YES

sulfa

YES

local anesthetic

YES

fluoride

YES

chlorhexidine (CHX)

YES

metals (nickel, gold, silver, etc)

YES

latex

YES

nuts

YES

fruit

YES

other

YES

3. heart problems, or cardiac stent within the last six months

YES

4. history of infective endocarditis

YES

5. artificial heart valve, repaired heart defect (PFO)

YES

6. pacemaker or implantable defibrillator

YES

7. orthopedic implant (joint replacement)

YES

8. rheumatic or scarlet fever

YES

9. high or low blood pressure

YES

10. a stoke (taking blood thinners)

YES

11. anemia or other blood disorder

YES

12. prolonged bleeding due to a slight cut (INR>3.5)

YES

13. pneumonia, emphysema, shortness of breath, sarcodidosis

YES

14. tuberculosis, measles

YES

14. (cont.) chronic ear infections

YES

14. (cont) Chicken pox

YES

15. asthma

YES

16. breathing or sleep problems (eg. sleep apnea, snoring, sinus)

YES

17. kidney disease

YES

18. liver disease

YES

19. jaundice

YES

20. thyroid, parathyroid disease or calcium deficiency

YES

21. hormone deficiency

YES

22. high cholesterol or taking statin drugs

YES

23. diabetes (HbA1c=_______)

YES

24. stomach or duodenal ulcer

YES

25. digestive or eating disorder (eg, celiac, GERD, bulimia, anorexia)

YES

26. osteoporosis/osteopenia (taking bisphosphonates)

YES

27. arthritis

YES

28. autoimmune disease

YES

29. glaucoma

YES

30. contact lenses

YES

31. head or neck injuries

YES

32. epilepsy, convulsions (seizures)

YES

33. neurologic disorders (ADD/ADHD, prion disease)

YES

34. viral infections and cold sores

YES

35. any lumps or sweeling in the mouth

YES

36. hives, skin rash, hay fever

YES

37. STI/STD/HPV

YES

38. Hepatitis (type: ________)

YES

39. HIV/AIDS

YES

40. tumor, abnormal growth

YES

41. radiation therapy

YES

42. chemotherapy

YES

42. (cont.) immunosupproesive medication

YES

43. emotional difficulties

YES

44. psychiatric treatment

YES

45. antidepressant medication

YES

46. alcohol/recreational drug use

YES

ARE YOU:

47. presently being treated for any other illness

YES

48. aware of a change in your health in the last 24 hours (eg. fever chills, new cough or diarrhea)

YES

49. taking medication for weight management?

YES

50. taking dietary supplements?

YES

51. often exhausted or fatigued

YES

52. experiencing frequent headaches

YES

53. a smoker, smoked previously or use smokeless tobacco

YES

54. considered a touchy/sensitive person

YES

55. often unhappy or depressed?

YES

56. taking birth control pills

YES

57. currently pregnant

YES

58. diagnosed with prostate disorder

YES

describe any current medical treatment, impending surgery, genetic/developmental delay or other treatment that may possibly affect your dental treatment (ie. botox/collagen injections):

list all medications, supplements, and/or vitamins taken within the last two years (drug and purpose):

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISOTRY OR ANY MEDICATIONS YOU MAY BE TAKING

Dental History

Previous Dentist

How would you rate the condition of your mouth? (excellent/good/fair/poor?)

How long have you been a patient?

Date of most recent dental exam

Date of most recent x-rays?

How often do you visit the dentist?

What is your immediate concern?

PERSONAL HISTORY

Please choose YES or NO for all questions below.

1. Are you fearful of the dentist?

YES

2. Have you had an unfavorable dental experience?

YES

3. Have you had complications from past dental treatment?

YES

4.Have you ever had trouble getting numb or had any reactions to local anesthetic?

YES

5. Did you ever have braces, orthodontic treatment or had your bite adjusted? at what age?

YES

6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

YES

GUM and BONE

7. Do your gums bleed or are they sensitive?

YES

8. Have you ever been treated for gum disease?

YES

9. Have you ever noticed an unpleasant odor in your mouth?

YES

10. Is there anyone with a history of periodontal diseease in your family?

YES

11. Have you ever experienced gum recession?

YES

12. Have you ever had any teeth become loose on their own (without injury), or do you have difficuly eating an apple?

YES

13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

YES

TOOTH STRUCTURE

14. Have you had any cavities within the last 3 years?

YES

15. Does the amount of saliva in your moth seem too little or do you have difficulty swallowing any food?

YES

16. Do you feel or notice any holes on the biting surfaces of your teeth?

YES

17. Are any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth?

YES

18. Do you have grooves or notches on your teeth near the gum line?

YES

19. Have you ever broken teeth, chipped teeth or had a toothache or cracked filling?

YES

20. Do you frequently get food caught between any teeth?

YES

BITE AND JAW JOINT

21. Do you have problems with your jaw joint? (pain, sounds, opening, locking, popping)

YES

22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

YES

23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagles, or other hard/dry foods?

YES

24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?

YES

25. Are your teeth becoming more crooked, crowded or overlapped?

YES

26. Are your teeth becoming more loose?

YES

27. Do you have trouble finding your bite, or need to squeeze your teeth together or shift your jaw to make your teeth fit together?

YES

28. Do you place your tongue between your teeth or close your teeth against your tongue?

YES

29. Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits?

YES

30. Do you clench or grind your teeth together in the daytime or make them sore?

YES

31. Do you have any problems with sleep (ie restlessness or teeth grinding), wake up with a headache or awareness of your teeth?

YES

32. Have you ever worn a bite appliance?

YES

SMILE CHARACTERISTICS

33. Is there anything about the appearance of your teeth that you would like to change?

YES

34. Have you ever whitened (bleached) your teeth?

YES

35. Have you felt uncomfortable or self conscious about the appearance of your teeth?

YES

36. Have you been disappointed with the appearance of previous dental work?

YES

Patient, Parent or Guardian

Name

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I consent to use Electronic Records and Signatures (Read Electronic Record and Signature Disclosure)

Relationship to patient

Name