PATIENT HEALTH HISTORY
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1 PATIENT HEALTH HISTORY Your name Your regular dentist is Ever been a patient here before? YES NO Today's date Your physician is Your current age (Check all that apply) Have you ever had an adverse reaction to: Local Anesthetics/Novocain Codeine Antibiotic Other Aspirin/Advil Latex Do you take: Blood thinners (e.g Coumadin, Plavix, etc.) if yes, date and score of most recent INR Any other medications, vitamins or supplements, if so, please list: Name of medication What condition you take it for (List any additional meds you take on separate sheet) What is your level of anxiety/stress/fear when going to the dentist? None Mild Severe Mod Other Medical conditions (Check all that apply) Asthma if yes, where do you keep your inhaler? Bleeding problems Epilepsy Prosthetic heart valve Artificial joint Hepatitis Tuberculosis HIV/AIDS Thyroid Disease Cancer Chemo/radiation Sleep apnea Steroid Use Kidney Problems Psychiatric therapy Change in health in last year Any Addiction Breathing/COPD Heart Disease Vertigo Cold Sores/fever blisters
2 Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health of the following patients: (Please check all that apply) Tobacco user Diabetes Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease (and since gum disease only worsens that risk) it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease. Current Tobacco user What form (cig, pipe, chew, etc). How much/day For how long Previous Tobacco user When did you quit Diabetes is a well- known risk factor for gum disease. Research is confirming that when left untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum disease can improve your blood sugar control reducing your risk for the serious complications. How is your diabetes control? Good Fair Poor Date of last A1c What score? Who is your diabetes Doctor Family history of gum disease Some people are genetically prone to developing gum disease even if they take decent care of their mouths. Do you have any family history of gum disease? Yes No Don t know Stress Stress is a well- known risk factor for gum disease. Is your stress level too high? Yes No Life altering events (loss of job, divorce, death in family, moving to new location, etc.) can be particularly strong factors for gum disease. Are you currently going through and life altering events? Yes No Rheumatoid Arthritis There is a bi-directional connection between rheumatoid arthritis. If you have arthritis you are at an increased risk for gum disease. Emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of arthritis. Have you ever been diagnosed with Rheumatoid Arthritis? Yes No Being overweight is now recognized as a strong risk factor for gum disease. Obesity and gum disease are both risk factors for heart disease and diabetes. Thus, if you are over your ideal weight it is vitally important for you to eliminate any gum inflammation to lower your risks for more serious health problems. Overweight We can calculate your weight status by using Body Mass Index (BMI) List your current weight List your current height BM I=(703 x weight)/ (height) or below Underweight 18.5 to 24.9 Healthy weight 25.0 to 29.9 Overweight >30.0 Obese
3 All patients please complete the following (check all that apply) Heart disease/risk factors for heart disease (family history of heart disease, cholesterol, blood pressure Spouse with gum disease (Gum disease may be transmissible, family members should be screened for gum disease) Taking Dilantin, Ca+ Channel Blockers, or Immunosuppressants for organ transplantation Previous bouts of gum disease Family history of Alzheimer s disease History of gastric ulcers Respiratory disease Kidney Disease Family history of colon cancer FEMALES Are you: Pregnant Nursing Taking birth control pills Ever diagnosed with breast cancer? Family history of breast cancer? Post-menopausal? Do you have osteoporosis? Yes No Have you ever been tested for osteoporosis? Yes No Ever taken Fosamax, Fosamax Plus D, Actonel, Boniva, Didronel, Skelid, Aredia, Bonefors, or Zometa for osteoporosis or for any other reason? Yes No
4 STAFF MEETING AGENDA 1. What is our current understanding of the periodontal disease process? 2. What is our main message about periodontal disease: To patients? To medicine? 3. Which patients are priority patients? (Patients with risk factors for periodontal disease or risk factors for diseases affected by periodontal disease)? 4. What office systems do we use to identify, educate, and motivate specific patients? 5. What are our protocols for Host modulation therapy: Anti-inflammatory? Nutrition and Obesity? Anti-oxidation? 6. Which sites we treat? 7. What is our end point of procedure? 8. What is the end point of therapy (what are we trying to achieve)? 9. What is our pain/anxiety protocol during debridement? 10. Which adjunctive therapies do we use/when do we use them? 11. When do we refer patients? 12. Where do we get our information to stay current and up to date? 13. Where should we go for vacation when production triples?
5 The least important thing we did today was clean your teeth. Stop coming to us just to get your teeth cleaned! You should be seeing us regularly since only with our help can you keep oral inflammation to a minimum over your lifespan. That s really important. Here s why Dentistry has actually known for some time that if you have gum inflammation, cleaning the teeth will make them feel good for a day or two but will have no effect on eliminating the underlying inflammation. Medical research is confirming that inflammation anywhere in the body is a significant factor in many of the chronic diseases of aging (heart disease, diabetes, cancer, Alzheimer s disease). It turns out that the mouth is a significant source of inflammation when gum disease is present. Gum inflammation rarely causes any symptoms - most people who have gum inflammation do not even know it. Gum inflammation occurs when microscopic bacteria, in the form of a biofilm, collect below the gum line beyond where your toothbrush can reach. Left unchecked, this biofilm causes the silent inflammation in your mouth that can lead to other serious health problems. Inflammation in the body is now recognized as the cause of many serious chronic diseases. The mouth is a significant source of inflammation when gum disease is present. While everyone has bacteria in their mouth not everyone develops gum inflammation. There are identifiable risk factors that make some people more susceptible to gum inflammation. We know that it takes about 3-6 months for the inflammation-causing biofilm to reform underneath the gum line. Thus, if you have gum disease risk factors it is even more important for you to partner with us on a regular basis to determine if any gum inflammation has developed and then to do what is necessary to eliminate it. focused on determining: In this new era of dental medicine, your regular visits to a dental profession should be mainly 1. If there any areas of gum inflammation in your mouth. 2. If you have any risk factors for gum disease. 3. The method which will result in the most rapid elimination of your gum inflammation. 4. A customized daily program which will allow you to keep gum disease at bay. Only after that is accomplished Partnering with us over your lifespan to keep oral inflammation to a minimum will pay dividends to your oral and overall health.
6 OUR OFFICE PROTOCOL AT MAINTENANCE VISITS DIAGNOSIS 1. Med history review: Any necessary precautions due to medical conditions? Look up any drugs of which you are not familiar and define them on the health history sheet Determine if there are interactions between patient drugs and drugs we use? Are there any drugs that increase patient s risk for perio disease? 2. Risk assessment and counseling Discuss the patient s answers on their Risk Assessment Form Transfer pertinent risk information to charting Send marketing letter to physician? 3. Soft tissue (recession) and extra oral exam 4. Previous treatment history 5. Radiographic review Scan left to right six times looking for: 1 st interproximal caries 2 nd occlusal caries 3 rd crestal bone 4 th root surfaces and furcations 5 th root apices 6 th overall view (any other pathology) 6. Mobility/occlusal check Use two instrument handles to determine if any abnormal mobility is present If pathologic mobility is noted, determine if it is due to: 1. Bone loss (reduced bone support) 2. Occlusal trauma 3. Periodontal inflammation 7. Periodontal assessment sextant by sextant We probe for five bits of information at each site: 1. Inflammation is there any BOP or other signs of inflammation 2. Probing depth has it changed? 3. Debris quality and quantity (tactile and visual) 4. Subgingival contour - Is site maintainable and accessible by you and by patient (are there any debridement difficulty factors such as deep pockets, pockets in inaccessible areas, furcations, subgingival margins, contoured root surfaces) 5. Assess patient s pain tolerance do you need local anesthetic 8. OH assessment at problem spots Due to correctable patient inability? Due to local factors? 9. Caries exam 10. Esthetic/functional exam 11. Present diagnosis and treatment 12. Discuss treatment, alternatives, risks and benefits
PATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:
PATIENT FORMS Patient Information Name: Birth Date: Social Security #: Home Phone: Cell Phone: Email: Address: City: State: Zip: Responsible Party Name of person responsible for this account: Relationship
STEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
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PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
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