Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.

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Transcription:

(847)392-4422 afgd 1307@gmail.com Dental History What is the reason for your visit today? Date of Last Dental Visit: Last Dental Cleaning Last set of X-rays What was done at your last dental visit? Q Cleaning Q General Check up Q Problem Focused f problem focused, please describe: Previous Dentist Name: Previous Dentist Phone Number: information needed to gather previous x-rays, notes, ect. How often do you have dental exams? ^_) Never t \ Twice a year / When think need it (3 Once a year (^) Everytime get my teeth cleaned (_J Randomly How often do you brush your teeth? _) Once a day When have time {_) Twice a day Q Not to sure More than twice a day Page 1 of 6

(847)392^422 afgd1307@gmail.com How often do you floss? * O Once a day Q Twice a day Q When have time Q Not to sure Do you have any dental problems now? * O Yes Q No More than twice a day Have you ever used or are currently using topical floride? * Q Yes Q No Check all that apply: * My teeth are sensitive to hot or cold My teeth are sensitive with sweets My teeth hurt while biting or chewing 11 get blisters on my lips My gums bleed 11 have bad tastes in my mouth 11 have noticed loose teeth My parents had gum disease 11 clench and/or grind my teeth 11 put obects between my teeth (pens..) J My aw tires easily i 11 get cold sores 11 get oral lesions My gums hurt 11 have a bad odor in my mouth see a different in my bite My parents experianced tooth loss 11 bite my cheek and/or lip regularly breathe with my mouth open 11 snore 11 have a sleep disorder 11 get food caught between my teeth f food gets stuck between your teeth, where? 11 smoke/chew tobacco Are you satisfied with your teeth's appearance? J Yes Q No Page 2 of 6

dassociates for General Dentistry, Ltd. (847)392-4422 afgd1307@gmail.com Check all that apply, if you have ever had: orthodontic treatment oral surgery peridontal treatment bite adustment ) bite plate mouth guard clicking or pooping of the aw headaches, neckaches, or sholder aches difficulty opening or closing your mouth difficulty chewing Have you ever had a serious inury to the mouth or head? ^J Yes O No Do you feel nervous about having dental treatment? Yes (J No f yes, what is your biggest concern? Have you ever had an upsetting dental experiance? O Yes O No s there anything else about having dental treatment that you would like us to know? Q Yes O NO Page 3 of 6

=Associates for General Dentistry, Ltd. (847)392-4422 afgd1307@gmail.com Medical History Physcians Name: Physician's Phone # Have you had any medical care within the last two years, or have you been a patient in the hospital during the past 5 years? J Yes (J No Are you currently taking, or have taken in the last two years, any medication, drugs, pills, or herbal remedies, including regular dosages of aspirin? *UYes UN Have you ever taken one of these medications for bone loss? Q Fosamax O Actonel Q Boniva (^} any bishosphonates Q no, never have Are you aware of having an allergic (or adverse) reaction to any substance or medication? ( Yes O No f yes, please specify: Page 4 of 6

(847)392^422 afgd1307@gmail.com Please indicate which of the following you have, or have had in the past. *Pre-Med - Amox _ *Pre-Med-Clind *Pre-Med-Other (Anemia Arthritis/Rheumatism Artificial Joints Asthma Blood Disease Blood Tranfusion Bruise Easily Cancer (Chemotherapy (Chest Pain Chronic Cough Clotting Cold Sores/Blisters Cong. Heart Disease Contact Lenses Crohns disease Crotisone Medicine Diabetes Diet (restricted) Dizziness Emphysema/COPD Epilepsy or Seizures Excessive Bleeding Fainting /Dizziness Glaucoma LH..WA..D.S. Hay Fever/Hives (Head nuries ] Heart Disease Heart Murmur (Hemophilia Hepatitis High Blood Pressure Kidney Disease Low Blood Pressure Nervous/Anxious Pacemaker/AHV Pregnant/Nursing Rheumatic Fever Latex Sensitivity _JMS [ (Neuro Disorder (Parkinsons Disease Radiation Therapy ( Sickle Cell Disease Liver Disease LJMVP LJ tner Phychiatric Care Respiratory Problems Sinus Problems Skin cancer Smoker Stroke Swollen Ankles Tumors Weight ssues Synthroid J Ulcers (Tuberculosis (Venereal Disease f you have or have had any disease, condition, or problem not listed, please list: Page 5 of 6

(847)392-4422 afgd1307@gmail.com Do you have any questions for the doctor at this point in time? * t^j Yes O No f so, please comment below: 11 understand the above information is necessary to provide me with dental care in a safe and efficient manner. have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency, whom may release such information to you. will notify the doctor of any change in my health or medication. Signature: Date: Response Date: Page 6 of 6

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