Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4

Transcription

1 Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA (805) Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone Work Phone: Please Circle Your Answer: Sex (M ) / (F) Marital Status (Married/Domestic Partnership) (Widowed) (Divorced/Separated) (Single) (Minor/Child) Employer Employer Phone Address City State Zip Spouse/Parent City State Zip Whom may we thank for referring you? Responsible Party Name of Person Responsible For Account Relation to Patient Address City State Zip Home Phone Cell Phone Work Phone: Employer Employer Phone Address City State Zip Please checkmark all that apply and make notes necessary notes on the right: Have active tuberculosis Persistent cough greater than 3 weeks Cough that produces blood Been exposed to anyone that has tuberculosis If you have checked any of the above answers, please stop and see the receptionist. Page 1 /4

2 Dental History Reason for today's visit Date of last dental care Former dentist Date of last X-rays (approx.) Specific dental concerns or any problems with previous dental care? How do you feel about your smile? How often do you floss? How often do you brush? Please check or circle all that apply: Sensitivity to cold Grinding teeth Sensitivity to hot Loose teeth/broken fillings Bleeding gums Sensitivity biting Clicking popping Periodontal (gum) treatment jaw Bad breath Earaches/neck pains Sensitivity to sweets Sores or growths in your mouth Dry mouth Dentures or partials Previous or current Previous/current serious orthodontic treatment injury to the mouth Do you regularly Food collecting drink bottled water between teeth Medical History Physicians name (and city if not in SLO area) Date of last visit Are you in good health? Yes No Have you been hospitalized or had a major Yes No illness/surgery in the past 5 years? Have there been any significant changes to your health in the past year? Yes No If you have experienced a significant change in health or a major/illness surgery please explain below: Are you currently taking any prescriptions or over the counter medications including vitamins or supplements? Yes No Please list below Page 2 /4

3 Do you wear contact lenses Yes No Do you use controlled substances (drugs)? Yes No Have you had an orthopedic Yes No Do you use tobacco (smoking, chew, snuff)? Yes No total joint replacement? (hip, knee, finger, etc.) Date: Any Complications? If yes are you interested in stopping? Very /Mildly /Not Interested Are you taking or are you scheduled to take Do you drink alcoholic beverages Yes No either of the medications, alendronate If yes how many in the past 24 hours? (Fosmax ) or risedronate (Actonel ) for How many drinks do you have per week? osteoporosis or Paget's disease? Yes No Women Only: Are you Since 2001, were you treated or are you presently Pregnant? Yes No scheduled to begin treatment with the intravenous Number of weeks biphosponates (Aredia or Zometa ) for bone Taking birth control or pain or skeletal complications from Paget's hormonal replacement? Yes No disease, or metastatic cancer? Yes No Nursing? Yes No Date treatment began? Allergies: Please check or circle all substances you are allergic to or have had a reaction to: Local Anesthetics Penicillin/Antibiotics Aspirin Barbiturates, sleeping pills, sedatives Sulfa Drugs Codeine or other Metals Latex (Rubber) narcotics Iodine Hay Fever Animals Food Seasonal Allergies Other (please specify) Please specify the allergic response for all checkmarked substances below: Please check or circle if you have had any of the following diseases or problems: Artificial Heart Previous infective Damaged valves in Valve endocarditis transplanted heart Congenital Heart (CHD) Unrepaired cyanic CHD Repaired completely Repaired CHD with residual defects in the last 6 months Except for the conditions listed above antibiotic prophylaxis is no longer recommended for any other form of CHD Page 3 /4

4 Please check or circle if you have had any of the following diseases or problems: Cardiovascular Arteriosclerosis Angina Congestive Heart Failure Damaged Heart Heart Attack Heart Murmur Low Blood Pressure Valves High Blood Pressure Pacemaker Mitral Valve Prolapse Other Congenital Heart Defect Rheumatic Fever Anemia Abnormal Bleeding Rheumatic Heart Blood Transfusion Hemophilia HIV/AIDS Rheumatoid Arthritis Date Arthritis Systematic Lupus Asthma Autoimmune erythmatosus. Bronchitis Emphysema Sinus Trouble Tuberculosis Cancer / Chemo. Chest Pain w/ Chronic Pain Diabetes Radiation Treatment Exertion Type Eating Disorder Malnutrition Gastrointestinal G.E. reflux / persistent heartburn Ulcers Thyroid problems Glaucoma Hepatitis, Jaundice or Liver Stroke Epilepsy Fainting spells or Neurological disorders seizures Specify Sleep Disorder Mental Health Dis. Recurrent Infections Kidney Problems Specify Specify Osteoporosis Persistent swollen Severe headaches Severe/rapid weight loss glands in neck migraines Sexual Transmitted Excessive urination Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment? If yes for what reason? Name of physician making recommendation: Do you have any disease, condition or problem not listed above that you believe I should know about? Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the dentist, or any member of her staff, responsible for any action they take or do not take because of errors or omissions, that I may have made in the completion of this form. Page 4 /4

5 Signature of Patient (or Legal Guardian) Date Page 5 /4