DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings breaking Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, tipped or shifting teeth Bad Breath Do you have any of the following? Dentures Partial Dentures Braces Gum Treatments Please share the following dates: Your last cleaning Your last oral cancer screening Your last complete x-rays Name of Previous Dentist _ City State Phone What is the most important thing to you about your future smile and dental health? Medical History Please check any of the following that apply to you: Allergies Excessive Bleeding Anemia Glaucoma Artificial Heart Valve Heart Conditions Artificial Joints Heart Murmur Asthma Hepatitis A Blood Disease Hepatitis B Bruise Easily Hepatitis C Cancer High Blood Pressure Chemotherapy HIV / AIDS Diabetes Jaundice Dizziness / Fainting Kidney Disease Drug Addiction Liver Disease Emphysema Mitral Valve Prolapse Do you have an allergy to any of the following? Aspirin Erythromycin Latex Local Anesthtic Nitrous Oxide Penicillin Codeine KODISH DENTAL GROUP Other If you could whiten your teeth for a cost anyone could afford, would you do it? Y N Do you smoke or use chewing tobacco? Y N How much? For how long? If I could change my smile, I would: Make my teeth whiter Make my teeth straighter Close spaces Replace metal fillings with tooth colored restorations Replace missing teeth Replace old crowns that don t match Have a smile makeover On a scale of 1-10, with 10 being the highest rating: How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10 Where would you rate your current dental health? 1 2 3 4 5 6 7 8 9 10 Why did you leave your previous dentist? What is the most important thing to you about your dental visit today? Nervousness/Depression Pacemaker Phen Fen (1 month+) Radiation (Head/Neck) Respiratory Problems Rhuematic Fever Rhuematism Scarlet Fever Seizures Stomach Problems Stroke Thyroid Disease Tuberculosis Ulcers Other (Please list) FOR WOMEN ONLY Birth Control Pills Breast Feeding Pregnant (Months) 1-3 3-6 6+ What Medications are you currently taking? Are you under a physician s care? For what? Family Physician Phone Number
HEADACHE HISTORY PATIENT INFORMATION NAME DATE AGE SEX Copyright 2011 D.R.S. All Rights Reserved. Rev 090611 TELEPHONE TODAY / / Please review and answer all parts of each question with our staff. Provide specific details/notes in the righthand column. # QUESTIONS 1 How often do you get severe headaches/migraines that make it difficult to function without treatment or medication?» Occasionally» More than twice a year» More than once a month» More than once a week 2 How often do you get other milder headaches?» Daily» More than 3 per week» More than 2 per month» Other Please specify: 3 Have your headaches changed in the last six months?» About the same» Slight worsening» Same but more frequent» A lot worse» Got worse when 4 What other doctors have you seen or tests have you had? 5 What medications do you use for headache, migraine, or pain relief? MEDICATION (NAME OF MEDICATION OR SUBSTANCE) WHAT DOSE? HOW OFTEN? Acetaminophen, Tylenol Ibuprofen, Advil, Motrin, Nuprin, etc.. Naproxin, Aleve Rx pain medication ( ) Rx pain medication ( ) Rx muscle relaxant ( ) Rx anxiety medication ( ) Rx depression medication ( ) Rx migraine medication ( ) Medication for sleeping ( ) Caffeine intake ( ) Alcohol intake ( ) THC, Medical Marijuana ( ) Other: ( ) I HEREBY ACKNOWLEDGE THAT THE ABOVE INFORMATION BEST DESCRIBES THE TREATMENTS AND MEDICATIONS I HAVE USED TO HELP ALLEVIATE MY HEADACHES/MIGRAINES/PAIN. PATIENT SIGNATURE:
PATIENT INFORMATION NAME DATE AGE SEX TELEPHONE TODAY / / HEAD HEALTH HISTORY Copyright 2012 Dental Resource Systems, Inc. All Rights Reserved. Rev 041812A # DENTAL FOUNDATION (TEETH, MUSCLES, JOINTS) # SYMPTOMS 1 Have you noticed a change in the way your teeth fit together?» If Yes, it is because of Dental Changes Trauma Other 2 Where do you think your teeth hit or fit first? More on the right Left Equal More on the front Back Equal 3 Do your jaw muscles get tight or sore?» When? Morning Evening After chewing Yes No 12 Do you experience pain in» Jaw Right Left Both More than 1 year» Face Right Left Both More than 1 year» Neck Right Left Both More than 1 year» Shoulders Right Left Both More than 1 year» Arms Right Left Both More than 1 year 13 Do you experience ringing or fullness in your ears? Yes No» Which one? Right Left Both Yes No 14 How often do you get severe headaches/migraines that makes it difficult to function without treatment or medication? Occasionally More than twice a year More than once a month More than once a week Never 4 Do you have pain or difficulty opening wide? Yes No 15 How often do you get other milder headaches? Daily More than 3 per week More than 2 per month Other 5 Are you aware of noises in your jaw joints? Popping Clicking Other» Where? Right Left Both» How long? Less than 1 year More than 1 year Yes No 16 Have your headaches changed in the last six months? About the same Slight worsening Same but more frequent A lot worse Got worse when CAUSES & COMPLICATIONS 17 What is your stress level? Mild Moderate Severe 6 Do you grind or clench your teeth?» Do you wear a? Splint Night Guard Retainer Yes No 18 Do you have anxiety? Yes No Mild Moderate Severe 7 Have you had any significant dental treatments? Orthodontics Oral surgery / wisdom teeth removal Long dental appointments Other 8 Have you been in a car accident, major or minor?» How many?» When was the last accident? 0-6 Months 6-12 Months More than 1 year» Did you see the accident coming? Yes No» Did the airbag deploy? Yes No 9 Have you had sports injuries and/or trauma to your head & neck?» When? Less than 1 year More than 1 year 10 Do you work at a desk, computer or in a forward head posture position?» Do you have any other postural position problems? 11 Problems with sleep?» Insomnia Yes No» Sleep Apnea Yes No» Sleep Disturbances Yes No» Less than 7 hours per night Yes No» Other Yes No 19 Because of pain, headaches or migraines, in the last month: # Of days you could not go to school # Of days you did reduced amount of work # Of days you could not do usual household work/parenting # Of days you missed family or social functions Yes No 20 When you have pain, headaches or migraines, how does that make you feel? (Check all that apply) Angry Depressed Tired or exhausted Frustrated Guilty Ashamed Relationship tension Other Yes No NOTES: Yes No FOR OFFICE USE ONLY Pain/Headache/Migraine Impact Score: MILD MODERATE SEVERE