Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,

Size: px

Start display at page:

Download "Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,"

Madeline Simpson
5 years ago
Views:

Tuolumne Me-Wuk Dental Clinic 19969 Greenley Road, Suite D Sonora CA 95370 Phone: 209-532 0034 Fax: 209-532 0036 Dear Patient, Welcome to the Tuolumne Me-Wuk Dental Clinic.

1 Tuolumne Me-Wuk Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient, Welcome to the Tuolumne Me-Wuk Dental Clinic. We are a department of the Tuolumne Me-Wuk Indian Health Center, owned and operated by the Tuolumne Band of Me-Wuk Indians. Please complete and sign the following registration documents: 1. Patient Registration (2 pages) 2. Health History Questionnaire (1 page) 3. Broken Appointment Policy (1 page) What additional documents should I submit with my registration? 1. State issued Driver s License or Identification Card 2. Insurance card (front and back) If Native, please attach verification from a Federally Recognized Tribe or Bureau of Indian Affairs. If presenting tribal documentation not in your name, please provide birth certificate to show the lineage to the registered tribal member. If you have any questions, please do not hesitate to contact us at the number above. Thank you, and welcome! Tuolumne Me-Wuk Dental Clinic Office Staff

4 Health History Questionnaire 1. DENTAL HISTORY QUESTIONS Name: Date of Birth: a. What is the reason for your visit today? Are you in pain? Yes No b. Do you have a problem with your teeth that you would like us to address? Yes No c. When was your last Dental Exam? When was your last Dental Cleaning? d. How many times per day do you Brush? Floss? Do your gums bleed? Yes No e. Have you had radiation treatment to your head or neck? Yes No f. Have you ever had any sores or lumps in or near your mouth? Yes No Please explain: g. Have you ever had any trauma to teeth? Yes No Please explain: h. Do you have clicking or popping of your jaw? No Clicking Popping Grinding Lock Jaw Pain i. Have you ever had any of the following treatments? Oral Surgery/Tooth Extractions Periodontal/Gum Treatment Bite Guard Orthodontic Treatment Endodontic/Root Canal Treatment Crowns, Bridges, or Implants j. Have you ever had problems with prior dental treatment? Yes No Please explain: 2. HEALTH HISTORY QUESTIONS: a. How would you rate your current health? Good Fair Poor b. Has there been a change in your health within the last year? Yes No Please explain: c. Approximate date of last medical exam? d. Are you being treated by a physician now? Yes No For what conditions? e. Have you ever been hospitalized or had a serious illness? Yes No Please explain: f. Have you had any surgeries in the past five years? Yes No Please explain: h. Have you ever taken any bisphosphonates or bone-building medications? Yes No 3. DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING? (Please circle all that apply) High Blood Pressure Low Blood Pressure Heart Attack Endocarditis Prosthetic Heart Valve Mitral Valve Prolapse Heart Disease Heart Murmur Pacemaker Angina/Chest Pain Rheumatic Fever Stroke Abnormal Bleeding Anemia Hemophilia Radiation Therapy Psychiatric Care Epilepsy/Convulsions Fainting/Seizures Hepatitis/Jaundice Arthritis Swollen Ankles Hay Fever AIDS or HIV Joint Replacement Prosthetic implant Seasonal Allergies Glaucoma Leukemia Cancer Diabetes Asthma Emphysema Respiratory Problems Tuberculosis Unexplained Weight Loss Stomach Ulcers Colitis Thyroid Problems Liver Disease Kidney Disease Osteoporosis Contact Lenses Sjogrens Syndrome Speech impairment STDs Other: None of the above 4. DO YOU HAVE ANY REACTIONS OR ALLERGIES TO FOODS OR MEDICATIONS? No known allergies Latex Penicillin Erythromycin Tetracycline Sulfa Drugs Codeine Certain metals Other: 8. WOMEN ONLY: Are you or could you be pregnant? Are you taking Birth Control Pills? 5. ARE YOU TAKING OR USING ANY MEDICATIONS INCLUDING OVER THE COUNTER AND NATURAL REMEDIES? Please list them here: Are you nursing? 6. SMOKING HISTORY: Never Smoked Current smoker History of smoking Chewing tobacco History of chewing Smoker in home Smoke free home 7. DO YOU USE ANY OF THE FOLLOWING: Alcohol Recreational Drugs Prescription Controlled Substances

5 Tuolumne Me-Wuk Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Broken Appointment Policy We strive to reserve dental appointments at your convenience, and require a 24 hour notice for any changes. We encourage you to keep your reserved appointments so that your treatment is not delayed. A No Show is recorded when: A patient fails to show to a reserved appointment. A patient informs us that he/she is unable to keep a reserved appointment without a 24 business-hour notice. A patient is so late that scheduled treatment or alternate treatment cannot be done. If any patient has three No Shows within 12 months, then no future appointments can be scheduled unless the patient obtains a one-time exception from the Executive Director of the Tuolumne Me-Wuk Indian Health Center. I acknowledge and understand the above information, and all of my questions have been answered.

PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:

PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation: Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are