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: EMAIL 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?
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
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
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
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