Patient'S Questionnaire Form Page 2
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2PATIENT’S DENTAL HEALTH
Why have you come to see us today? (e.g.: pain, checkup, etc.) _______________________________________________________________________________________
Previous Dentist_______________________________________ Last Visit ___________________________________________ Date of last cleaning ________________
Reasons for changing dentists: _________________________________________________________________________________________________________________
What problems have you had with past dental treatment? ____________________________________________________________________________________________
☐ Yes!
☐ No If yes please, tell us why: _________________________________________________________________
Are you nervous about seeing a dentist?
☐ Yes ☐ No
How often do you brush? __________________________
Do you floss?
How often? ________________________________
(Please circle each)
Y N I clench or grind my teeth during the day or while sleeping.
Y N I avoid brushing part of my mouth due to pain.
Y N I have had a facial or jaw injury.
Y N My gums bleed while brushing or flossing.
Y N My gums feel tender or swollen.
Y N I want my teeth straighter.
Y N I would like to improve my smile.
Y N I have problems eating.
Y N I want my teeth whiter.
Y N I prefer tooth-colored fillings.
Y N I have had orthodontics.
What are your dental priorities? ________________________________________________________________________________________________________________
(e.g.: appearance, dental health, financial considerations, etc.)
☐ Excellent
☐ Good
☐ Fair
☐ Poor
PATIENT’S MEDICAL HISTORY
I consider my health to be (check one):
Do you have or have you had any of the follow? Please circle Y for yes or N for no.
1. Y N Heart Disease
25.
Y N
Liver Disease
39.
Y N HIV
2. Y N Heart Murmur/Mitral Valve Prolapse
26.
Y N
Jaundice
40.
Y N AIDS
3. Y N Stroke
27.
Y N
Hepatitis Type ___________
41.
Y N Immune Suppressed Disorder
4. Y N Congenital Heart Lesions
28. Y N
Diabetes
42.
Y N Hearing Loss
5. Y N Rheumatic Fever
29.
Y N
Excessive Urination and/or Thirst
43.
Y N Fainting Spells
30.
Y N
Infectious Mononucleosis (“Mono”)
6. Y N Pacemaker
44.
Y N Glaucoma
7. Y N Stent
31.
Y N
Herpes
45.
Y N History of Emotional or Nervous Disorders
8. Y N Abnormal Blood Pressure
32.
Y N Arthritis
9. Y N Anemia
33.
Y N
Sexually Transmitted/Venereal Diseases
WOMEN:
10. Y N Prolonged Bleeding Disorder
34.
Y N Kidney Disease
46.
Y N Are you taking birth control medication?
11. Y N Tuberculosis or Lung Disease
35.
Y N Tumor or Malignancy
47.
Y N Are you or could you be pregnant or nursing?
12. Y N Asthma
36.
Y N
Cancer/Chemotherapy
13. Y N Hay Fever
37.
Y N Radiation/Therapy
14. Y N Sinus Trouble
38.
Y N History of Drug Addiction
15. Y N Epilepsy/Seizures
Doctor Notes Only:
16. Y N Ulcers
17. Y N Implants/Artificial Joints:
Hip-Knee____________ Other ___________________________________
18. Y N I smoke or use chewing tobacco
If yes, how much per day? __________ How many years?______________
19. Y N I have consumed alcohol within the last 24 hours.
20. Y N I usually take antibiotic prior to dental treatment
21. Y N Have you ever taken Fen-Phen or Redux?
22. Y N Do you take or have you ever taken Bisphosphonates (Fosamax, Boniva, Actonel, Aredia, Zometa, etc.) for Osteoporosis or any other condition?
23. Y N I have had major surgery
Year _________________ Type of operation_______________________
Year _____________________ Type of operation __________________
24. Y N Do you have any other medical problem or medical history NOT listed on ths form? _________________________________________________________________________________
Are you allergic to any of the following?
Please list all medications you are currently taking:
Please circle y for Yes or N for no
48. Y N Aspirin
Medicine _______________________________ Condition _____________________________
49. Y N Ibuprofen
Medicine _______________________________ Condition _____________________________
50. Y N Sulfa Drugs/Sulfites/Sulfides
51. Y N Penicillin
Medicine _______________________________ Condition _____________________________
52. Y N Codeine
Medicine _______________________________ Condition _____________________________
53. Y N Latex, Metals, Plastics
Physician’s Name ___________________________ Phone _____________________________
54. Y N Local Anesthetics (i.e., Novocain, Lidocaine)
55. Y N Other Medications Which ones?
Address __________________________________ Fax ________________________________
In the event of an emergency please contact:
Name ______________________________________________ Relationship _____________________________________________ Phone_________________________
Name ______________________________________________ Relationship _____________________________________________ Phone_________________________
Initial medical/dental reviewed by:
X __________________________________________ / __________/__________
X ________________________________________________/ __________/______
Doctor’s Signature
Patient’s Signature
Date
Date
Periodic medical/dental health reviewed by:
X ________________________________________________/ __________/______
Patient’s Signature
Date
X ________________________________________________/ __________/______
X __________________________________________ / __________/__________
Patient’s Signature
Date
Doctor’s Signature
Date
X ________________________________________________/ __________/______
X __________________________________________ / __________/__________
If patient is a minor, Guardian’s Signature Required
Date
Doctor’s Signature
Date
X __________________________________________ / __________/__________
Doctor’s Signature
Date
GETTING TO KNOW YOU AS OUR PATIENT
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Parent category: Medical