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Transcript
Pueblo Community College Dental Health Questionnaire Today’s Date: _______________ Driver’s License #______________________ Exp. (mm/yyyy)___________________ Sex: M _____F______ Patient Name (First & Last) ______________________________________________Birthdate: ______/______/_____ Age: ____ Address ______________________________________________ City_____________________ State_____ Zip___________ Home Phone __________________________ Cell Phone ______________________ Work Phone _______________________ Spouse (if appropriate) or Emergency Contact _______________________________ Phone _____________________________ If patient is a minor child or dependent adult, what is the relationship of the person who brought the child to this clinic? Parent_____________________ Relative____________________ Legal Guardian________________ Other________________ Name of legal guardian or caretaker: __________________________________________________________________________ Physician Name: ___________________________________________ Physician Phone: _______________________________ Dentist Name: ______________________________ Dentist Phone: __________________ Date of Last Visit________________ Would you object to consultation with your Dentist or Physician, should a need arise? No Yes (please comment if yes) _____________________________________________________________________________________________________ Please explain the symptoms or complaint for which you are now seeking care_________________________________________ _____________________________________________________________________________________________________ A. DENTAL HISTORY Check any of the following conditions that apply Have you ever been treated for any of the (four) conditions below? Sores in your mouth Periodontal Treatment (gum surgery) Sensitive teeth Orthodontics (braces) Bleeding gums Endodontics (root canal) Difficulty chewing Dental Extractions, Fillings Pain in the jaw joints Dry mouth Dental pain/discomfort Do you drink bottled or filtered water? If yes, how often? Circle One: Daily / Weekly / Occasionally Anxious about receiving dental treatment Injury to face or jaw Have you ever had complications during previous dental treatment? Yes No Have you ever had a reaction to a local dental anesthetic (injection to numb)? Yes No Do you have any of the following dental habits: Clenching / Grinding / Chewing objects Do you use any tobacco products? Do you bleed easily? Yes Yes No No Continued on next page B. HEALTH HISTORY Check any of the following past or present conditions that apply: Congestive Heart Disease Heart Disease or Attack? Date_______ Angina Pectoris High Blood Pressure Congenital Heart Disease (CHD) Artificial Heart Valve Heart Pacemaker Heart Surgery? Date_________ Previous infective endocarditis Damaged valves in transplanted heart Unrepaired valves in transplanted heart Unrepaired, cyanotic, CHD Repaired CHD with residual defects Emphysema or Lung Disease Tuberculosis Asthma Diabetes Last A1C #______ Thyroid Disease Cancer or Tumor Chemotherapy X-ray/Cobalt Treatment Arthritis, Rheumatism Steroids/Cortisone Medicine Glaucoma Back Trouble/Surgery Kidney Trouble or Disease HIV+/AIDS Hepatitis A (infectious) Hep B(serum) Hep C Liver Disease or Yellow Jaundice Drug Addiction STD’s Epilepsy or Seizures Psychiatric Treatment Sickle Cell Disease Surgery Stroke Anemia/Bleeding Disorders Disability (hearing, vision, etc.) Other conditions past or present not listed _____________________________________ Osteoporosis: Have you been diagnosed with Osteoporosis? Yes No Allergies: Are you allergic to or have had a reaction to any of the following: Have you taken, are taking, or scheduled to take Bisphosphonates? (Aredia, Fosamax, Boniva, Actonel, etc.) If yes, please list.___________________________________ _________________________________________________ Local anesthetics Joint Replacement (Artificial Joint): If yes, date________________ Type __________________ _______________ ___________________ Please Circle Sulfa drugs Aspirin Iodine Penicillin Latex (rubber) Amoxicillin Codeine Other _____________ FEMALES ONLY: Are you presently pregnant or trying to become pregnant? Yes, number of weeks__________ No Have you had any complications? Yes No If yes, specify_____________________________________ Using birth control drugs? (pills, patches, implants, etc.) Yes No Name of physician__________________________________ Are you nursing? Yes No Please list any disease associated with your family history: __________________________________________________________________ Are you presently under active treatment by a physician? If so, for what and when? _____________________________________________ _________________________________________________________________________________________________________________ Are you presently taking any prescription or recreational drugs? If so, please list the medications and for what condition(s). _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/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 my dentist, or any other member of his/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. Patient or Guardian__________________________________________________________ Date______________________________________ *********************************************************************************************************** Clinic Use Only Signature of Student Clinician: ________________________________ Signature of Faculty: ____________________________ Signature of Dentist (Dental Clinic only)_____________________________________________________________________
