ORAL SURGERY/IMPLANT CONSULTATION
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- Marjory Wheeler
- 5 years ago
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1 ORAL SURGER/IMPLAT COSULTATIO Form 401C This questionnaire was designed to provide important facts regarding the history of your pain or condition The information you provide will assist in reaching a diagnosis and determining the best treatment. Please take your time and answer each question as completely and honestly as possible. Please sign each page. PATIET IFORMATIO TODA'S DATE: MR. MS MISS MRS. DR. AME: FIRST MIDDLE IITIAL LAST AGE: BIRTH DATE: MALE FEMALE ADDRESS: CIT/STATE/ZIP: HOW LOG AT CURRET ADDRESS? (IF LESS THA 3-EARS PLEASE GIVE PREVIOUS ADDRESS) PREVIOUS ADDRESS EMPLOED B: ADDRESS: OCCUPATIO REFERRED B: SS#: HOME PHOE: WORK PHOE: CELL PHOE: RESPOSIBLE PART: ADDRESS IF DIFFERET FROM PATIET FAMIL PHSICIA ADDRESS FAMIL DETIST ADDRESS DO A OF THE FOLLOWIG CHIEF COMPLAITS APPL TO OU? Diet limited to semisolid food or soft foods Diet limited to liquid foods Difficulty chewing Difficulty speaking Difficulty swallowing Digestive problems Facial pain Gagging easily Mouth sores umbness in lower lip umbness in jawbone Tingling in jawbone utritional disorders Pain in jaw bone Pain in jaw joint Pain when swallowing Head pain Pain when chewing Jaw clicks Poorly fitting dental appliance Jaw locks upper lower Limited opening of jaw Teeth do not meet properly Loss of teeth Are you currently in pain? Do you feel your oral condition is affecting your general health in any way?
2 Form 401C - Page 2 LIST A MEDICATIOS/SUBSTACES WHICH HAVE CAUSED A ALLERGIC REACTIO: Antibiotics Aspirin Barbiturates Codeine Iodine Latex Local anesthetics Metals Penicillin Plastic Sedatives Sleeping pills Sulfa drugs LIST A MEDICATIOS CURRETL BEIG TAKE: Antibiotics Anticoagulants Barbiturates Blood thinners Codeine Cortisone Diet pills Heart medication Insulin Muscle relaxants erve pills Pain medication Sleeping pills Sulfa drugs Tranquilizers PLEASE LIST OTHER HEALTH CARE PRACTITIOERS SEE I THE LAST 9 MOTHS: Practitioner Specialty Treatment & Approximate date MEDICAL HISTOR (Please indicate dates on questions checked ES) Abnormal bleeding after surgery or injury Anemia Arteriosclerosis Asthma Autoimmune disorders Bleeding easily Bloating Chronic fatigue Chronic mouth dryness Cold hands & feet Colitis Current pregnancy Depression Diabetes Dizziness Emphysema Epilepsy Blood pressure High Low Bruising easily Cancer Chemotherapy Chronic Bronchitis Excessive thirst Fainting spells Fluid retention Frequent cough Frequent illnesses Frequent stressful situations General anesthesia Glaucoma Gout Hay fever Headaches Hearing impairment Heart murmur Heart disorder Heart pacemaker Heart palpitations Heart valve replacement Heart valve damaged Hemophilia Hepatitis Hypoglycemia Immune system disorder Injury to Face eck Mouth Teeth Insomnia Intestinal disorders Jaw joint surgery Kidney problems Liver disease Meniere's disease Menstrual cramps Multiple sclerosis Muscle aches Muscle shaking (tremors) Muscle spasms or cramps Muscular dystrophy eeding extra pillows to help breathing at night ervous system irritability ervousness euralgia Osteoarthritis Osteoporosis Ovarian cysts Parkinson's disease
3 MEDICAL HISTOR Continued Poor circulation Prior orthodontic treatment Psychiatric care Radiation treatment Rheumatic fever Rheumatoid arthritis Scarlet fever Seizures Shortness of breath Sickle Cell Anemia Sinus problems Skin disorder Slow healing sores Speech difficulties Stomach ulcers Stroke Form 401C - Page 3 Swelling of ankles Swollen, stiff or painful joints Tendency for: Frequent Colds Ear Infections Sore Throats Tired muscles Tuberculosis Tumors Urinary disorders Medical/Dental History Do you take aspirin regularly Smoke tobacco Has any close relative had a serious illness or condition Emotional or nervous disturbances? If yes, please explain COMPLETE THIS SECTIO IF OU WERE IVOLVED I A ACCIDET OR A TRAUMATIC ICIDET RELATED TO THIS VISIT THE PATIET BELIEVES THE CAUSE OF THE PAI OR CODITIO TO BE: A motor vehicle accident A motorcycle accident A work related incident A playground incident An athletic endeavor A fight A fall An accident Unknown HISTOR OF ACCIDET WERE OU? A passenger in a vehicle The driver of a vehicle A pedestrian At work IF I A VEHICLE WHERE WAS THE VEHICLE HIT? At front end At rear end At front right area At front left area At rear right area At rear left area DATE OF ACCIDET OR ICIDET: Did you fall? Were you hit by an object? Did you hit an object? Head on On driver's side On passenger's side IDICATE IF THERE WAS A DIRECT TRAUMA: DID OUR Forehead Face Chin Side of head Back of head Top of head Teeth Jaw FORCIBL STRIKE Steering wheel Windshield Passenger's side window Driver's side window Passenger's side door Driver's side door Headrest Seat Roof Interior of car TEETH WERE Sore Missing Loose Broken AFTER THE ACCIDET BRIEFL DESCRIBE THE HISTOR OF SMPTOMS, ACCIDET OR ICIDET: FOR OFFICE USE Extent of medical history obtained on consisted of: (date) Chief Complaint(s) Extended history of present illnesss Review of systems related to problem Review of all additional body systems Complete past history Complete family history Complete social history
4 Form 401C - Page 4 FAMIL HISTOR Have any members of your family (blood kin) had: Headaches High blood pressure Heart disease Diabetes SOCIAL HISTOR Occupation Do you have children? If yes, how many children? What are their ages? Are you currently under unusual stress? Recent change in lifestyle? Do you exercise regularly? Do you chew tobacco? umber of caffeine drinks per day Do you smoke? Alcohol consumption umber of Packs Cigarettes per Day Week umber of drinks per Day Week Month
5 Form 401C - Page 5 ISURACE IFORMATIO ISURACE #1 (MEDICAL/DETAL/AUTO/OTHER) Insured's ame Relationship Insured's Social Security. Insured's Birth date. Insured's Street Address Insurance Billing Address Policy. Group. I.D.. MEDICAL ISURACE #2 (MEDICAL/DETAL/AUTO/OTHER) Insured's ame Relationship Insured's Social Security. Insured's Birth date. Insured's Street Address Insurance Billing Address Policy. Group. I.D.. I authorize the release of a full report of examination findings, diagnosis, treatment program, etc. to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. Signed FOR OFFICE USE OL Group Health Auto Government Self Insured Dental Contact Person Phone. Today's Effective date of this policy Amount of deductible? At what percentage are benefits paid? Policy maximum? Policy exclusions Has it been satisfied? Is precertification required Can benefits be assigned to doctor? What information is needed to process this claim? For Fault: Amount of benefits Adjuster
HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE
HEAD, ECK AD FACIAL PAI QUESTIOAIRE Form 401A This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:
DATE OF HEALTH HISTORY UPDATE: THIS IS A HEALTH HISTORY UPDATE. PLEASE INDICATE ANYTHING REGARDING YOUR HEALTH (MEDICAL AND DENTAL) THAT HAS CHANGED SINCE YOUR LAST VISIT TO OUR OFFICE. THANK YOU. WHAT
PREVIOUS ADDRESS: EMPLOYED BY: ADDRESS: SS#: HOME PHONE: WORK PHONE:
SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with #1 being the most important.
SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Patient Health Questionnaire
Patient Health Questionnaire PATIENT Information Date of completion TM Mr. Ms. Miss Mrs. Dr. Name: First Middle Initial Last Age: Date of Birth: Referred by: DDS MD ENT DC Other Location and/or Phone Number
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
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?
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
SLEEP SCREENING QUESTIONNAIRE
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A B O U T Y O U D E N T A L I N F O R M A T I O N
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Patient Health Questionnaire. Last
Patient Health Questionnaire PATIENT INFORMATION Date of completion O MNDX TM OMr. 0Ms. 0Miss 0Mrs. []Dr. First Middle Initial Age: Date of Birth: Referred by: ODDS DMD DENT ODC 00ther Location and/or
Julia A. Hallisy, D.D.S., Inc.
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Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Sleep Patient Registration
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SLEEP SCREENING QUESTIONNAIRE
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MEDICAL HISTORY FULL NAME D.O.B. SEX
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PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
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PATIENT MEDICAL HISTORY
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KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
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Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
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PATIENT INFORMATION DENTAL HEALTH HISTORY
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Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
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WELCOME Patient Registration Date:
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GENERAL QUESTIONS CONTACT INFORMATION
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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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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
New Patient Registration Form
New Patient Registration Form Welcome to ABC Dental Office! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Patient Medical and Dental History Personal Information. Name Date
Patient Medical and Dental History Personal Information Name Date (Last) (First) (Middle) Address County City State Zip Day Phone Evening Phone Cell Phone Birth Date Age Occupation Sex M or F Social Security
Welcome to South 40 Dental! Tell Us About Yourself
Welcome to South 40 Dental! Tell Us About Yourself Name: Last First MI Title Preferred Name: Male Female Parent/Guardian Name if Under 18 Years Old: Address: City Prov. Postal Code Date of Birth (day)
Twohig Dentistry Dental and Oral Health Information
Twohig Dentistry Dental and Oral Health Information Patient s name: Date: Please describe any specific dental problem or discomfort you are having at this time: How long has it been present? If you have
REGISTRATION FORM PATIENT INFORMATION. Patient s last name: First: Middle: Marital status: Occupation: Employer: Employer phone #: Physician name:
REGISTRATION FORM PATIENT INFORMATION Patient s last name: First: Middle: Marital status: Address (write below): City: State: Zip code: Birth date: Age: Sex: Ú M Ú F Social Security #: Home phone #: Cell
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Pre-Admission Testing Questionnaire
Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist