Download Directions - Bellevue Specialized Dental Care

B
S
DC
Bellevue Specialized
Dental Care
Welcome to our office. We appreciate the confidence you place with us to provide oral medicine care. To assist us
in serving you, please complete the following forms. The information provided on these forms is important to your
care. If you have any questions, don’t hesitate to ask.
Patient’s Name
Sex
Male
Today’s Date
Age
Birth Date
Driver’s License #
Social Security Number
Female
Address
City
State
Zip Code
Billing Address (if different)
City
State
Zip Code
Home Phone
Work Phone
Spouse’s Name and Phone #
Mobile
Emergency Phone # (other than spouse)
Primary Dental Insurance
Group #
Subscriber’s Name
ID#
DOB
SS#
Secondary Dental Insurance
Group #
Subscriber’s Name
ID#
DOB
SS#
Primary Medical Insurance
Group #
Subscriber’s Name
ID#
DOB
SS#
Name of your Medical Doctor
Phone #
Date of last visit to medical doctor
Name of your Dentist
Phone #
Date of last visit to dentist
Referred to us by
Page 1
B
S
DC
Bellevue Specialized
Dental Care
Birth Date
Patient’s Name
Today’s Date
1. CHIEF COMPLAINTS
Oral Mucosa:
Redness/Inflammation
Ulcerations
Blisters
Yeast infection
White lesions
Growth or swelling
Burning tongue/mouth
Pain
Smell:
Strange smells
Persistent bad smell
Increased smell sensitivity
Reduced smell
Abnormal taste
Teeth:
Increased plaque
Excessive caries
Failing restorations
Erosion
Denture problems
Pain
Taste:
Breath odors
Persistent bad taste
Increased taste
Sensitivity
Reduced taste
Other:
Metallic taste
Salivary Glands and surrounding areas:
Swelling
Numbness
Palpable mass
Inflammation
Infection
Pain
Too much saliva
Too little saliva
Altered consistency
Drooling
Makes you nauseous
2. DETECTION OF PROBLEM (Please CHECK by your answer and fill in the blanks)
I detected the problem
My dentist found the problem
My physician found the problem
My fried/family found the problem
The first doctor I consulted:
The second doctor I consulted:
The third doctor I consulted:
Other doctors I consulted:
3. WAS THE ONSET OF YOUR SYMPTOMS RELATED TO ANY OF THE FOLLOWING?
Endocrine disease
Autoimmune disease
Neuralgic disease
Gastrointestinal disease
Flu or Cold
Hormonal changes
Stress
Depression
Other:
Anxiety
Reaction to medication
Radiation therapy
Surgical therapy of:
Ears, nose or throat
Temporomandibular Joint
Salivary gland
Cancer treatment
Happened while eating
Dental treatment
Work-related incident
Environment-related incident
Head trauma:
-Motor vehicle accident
-Assault/Abuse
-Unintentional
-Don’t know
Page 2
Patient’s Name
4. WHEN IS THE PROBLEM WORSE?:
At night
Upon awakening
During day
When eating
With specific foods
During stress
At work
With use of medication
Related to denture wearing
Other:
5. DO YOU USE ANY OF THE FOLLOWING TO ALLEVIATE SYMPTOMS?
Chewing gum
Candies or mints
Saliva substitute (Name:__________________)
Mouthwash (Name:__________________)
Other:
Frequent sips of water or liquid
Get up at night to drink water
Pain medications
Hot/cold packs
6. DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING?:
Salivary gland infections
Salivary tumor or cyst
Salivary obstruction
Salivary gland surgery
Radiation of salivary glands
7. DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS?:
Difficulty chewing dry food
Need water or liquid to help swallow
Pain with swallowing
Reflux problems
8. IF YOU HAVE OR HAVE HAD PAIN, PLEASE ANSWER THE FOLLOWING QUESTIONS:
A. Please MARK the locations of your pain: (R for right and/or L for left)
R L
R L
Scalp
Forehead
Neck
Temple
Shoulder
Cheek
Arm
Sinus
Back
Upper jaw
Chest
Lower jaw
Ear
TMJ (Temporomandibular Joint)
Eye
Lips
B. How long have you had this pain? _______________
C. Do you feel it is associated with your overall problem
D. When did it start in relation to your overall problem?
YES NO
Before
During
After
R L
Gum Tissue
Tongue
Throat
Roof of Mouth
Tooth
Extraction Site
Denture Ridge
Not applicable
Page 3
Patient’s Name
9. PAIN AVERSIVENESS RATING
Please rate how disagreeable or distressing the sensations you are feeling by making a mark on the line below.
Place your mark at a place on the line that corresponds to how aversive or unpleasant the pain is.
10 Extremely Aversive
0 Not Aversive
10. PAIN INTENSITY RATING
Please rate the strength of the pain you are experiencing by making a mark on the line below. Place your mark
at a place that corresponds to how intense your pain is.
0 Not Intense
10 Extremely Intense
11. WHAT DOES YOUR PAIN FEEL LIKE?
Some of the words below describe your PRESENT pain. Mark ONLY those words that best describe it. Leave out any
category that is not suitable. Use only a single word in each appropriate category -the one that applies best-. If you are
not feeling any pain at the moment, please leave box empty.
1
2
3
4
5
Flickering
Quivering
Pulsing
Throbbing
Beating
Pounding
Jumping
Flashing
Shooting
Pricking
Boring
Drilling
Stabbing
Sharp
Cutting
Lacerating
Pinching
Pressing
Gnawing
Cramping
Crushing
6
7
8
9
10
Tugging
Pulling
Wrenching
Hot
Burning
Scalding
Searing
Tingling
Itchy
Smarting
Stinging
Dull
Sore
Hurting
Aching
Heavy
Tender
Taut
Rasping
Splitting
11
12
13
14
15
16
Tiring
Exhausting
Sickening
Suffocating
Fearful
Frightful
Terrifying
Punishing
Gruelling
Cruel
Vicious
Killing
Wretched
Blinding
Annoying
Troublesome
Miserable
Intense
Unbearable
17
18
19
20
Spreading
Radiating
Penetrating
Piercing
Tight
Numb
Drawing
Squeezing
Tearing
Cool
Cold
Freezing
Nagging
Nauseating
Agonizing
Dreadful
Torturing
12. HOW HAS YOUR PAIN CHANGED SINCE THE ONSET?
Much improved
Improved
Slightly improved
Unchanged
Slightly worse
Worse
Much worse
Was worse, now better
Was better, now worse
Page 4
Patient’s Name
13. WHAT IS THE RECURRENCE PATTERN OF YOUR PAIN?
This is the first episode
Recurs several times daily
Recurs daily
Recurs weekly
Constant
Recurs monthly
Several recurrences a year
Recurs less than yearly
14. DIAGNOSTIC TESTS AND PROCEDURES
List in order all diagnostic tests and X-Rays, where they were conducted and results if you know them.
Test #1
Test #2
Test #3
Test #4
Location/Doctor
Location/Doctor
Location/Doctor
Location/Doctor
Finding
Finding
Finding
Finding
15. TREATMENTS
List in order all of the treatments you have received and CIRCLE the number indicating how successful the treatment
was. Include medications and physical therapy. NOTE: If no treatments, skip to next question.
NO
SOME
GOOD
COMPLETE
SUCCESS
SUCCESS
SUCCESS
SUCCESS
Treatment 1
0
1
2
3
Treatment 2
0
1
2
3
Treatment 3
0
1
2
3
Treatment 4
0
1
2
3
16. TREATMENT ADVERSE EFFECTS
If any of the treatments you have listed caused added problems, put the number of the treatment and describe the
problem it caused. If none, skip to the next question.
17. HOW HAS YOUR OVER-ALL PROBLEM CHANGED SINCE THE ONSET?
Much improved
Improved
Slightly improved
Unchanged
Slightly worse
Worse
Much worse
Was worse, now better
Was better, now worse
18. WHAT IS THE RECURRENCE PATTERN OF YOUR OVERALL PROBLEM?
This is the first episode
Recurs several times daily
Recurs daily
Recurs weekly
Constant
Recurs monthly
Several recurrences a year
Recurs less than yearly
Page 5
Patient’s Name
19. WHAT OTHER SYMPTOMS DO YOU HAVE?
Hearing loss
Motion sickness
Dizziness
Ringing ears
Plugged ears
Earaches
Frequent headaches
Neck pains
Neck lumps
Neck swelling
Weight loss
Weight gain
Loss of appetite
Always hungry
Always thirsty
Urinary frequency
Tend to feel hot
Tend to feel cold
Fatigue
Sleep difficulties
Coughing spells
Cough up phlegm
Cough up blood
Wheezing
Night sweats
Frequent colds
Blurry vision
Double vision
Eye pain or itching
Watery eyes
Eye Dryness
Trembling
Numbness
Paralysis
Faint Easily
Convulsions
Handwriting change
Sadness
Frustration
Anxiety
Worry
Bleed easily
Bruise easily
Skin rashes
Excessively dry skin
Itching or burning
Reflux
Heartburn
Stomach pains
Nausea
Constipation
Diarrhea
Congested nose
Runny nose
Head colds
Nose bleeds
Sore throat
Hoarseness
Enlarged tonsils
Chronic sinusitis
Hay fever
Mouth breathing
Nasal obstruction
Aching joints
Aching muscles
Back or shoulder pains
Muscle cramping
Arm/hand weakness
Indigestion
Chest pain
Shortness of breath
Racing heart
Fluid retention
Heart murmur
Sleep difficulties
Sexual difficulties
Reduced social activities
Problems at work
Comments:
20. FEMALES ONLY.
REGARDING YOUR REPRODUCTIVE SYSTEM, WHICH OF THE FOLLOWING APPLY?
Regular periods
Irregular periods
Menstrual pains
Going through menopause
Post menopausal
Presently pregnant (Month:____ )
Vaginal itching
Vaginal dryness
Recurrent vaginal yeast infections
Vaginal ulcers
Use birth control pills
Receive Depo-Provera injections
Hormone therapy
Hysterectomy (At age:___ )
Had ovary(ies) removed (At age:___ )
Comments:
Page 6
Patient’s Name
21. FAMILY MEDICAL HISTORY
Please Mark medical problems that have been present in your parents, brothers/sisters, children.
Cancer
Type:____________
Stomach or intestinal
problems
Ulcers
Kidney disease
Bladder problems
Drug abuse
Alcoholism
Arthritis
Back Pain
Hypertension
High Cholesterol
Heart disease
Glaucoma
Headaches
Migraine
Seizures
Malocclusion
Jaw Pain
Jaw locking
TMJ problems
Bruxism
Gout
Diabetes
Thyroid problems
Anemia
Blood coagulation
Genetic disease
Rheumatoid arthritis
Lupus Erythematosis
Other immune
system disease
Sleep difficulties
Anxiety
Depression
Suicide
Nervous breakdown
22. YOUR MEDICAL HISTORY, PAST & PRESENT ILLNESSES:
Cancer
Type:___________
Genetic disease
Type:___________
Rheumatoid arthritis
Lupus Erythematosis
Other autoimmune
disease
Diabetes
Gout
Obesity
Thyroid problems
Poor nutrition
Angina
Hypertension
Arteriosclerosis
High cholesterol
Other heart disease
Multiple sclerosis
Epilepsy
Neuralgia
Bells Palsy
Stroke
Migraine
Hearing loss
Visual loss
Glaucoma
Cataracts
Fractures
Concussion
Osteoporosis
Scoliosis
Back problems
Arthritis
Chicken pox
Herpes Zoster
Dermatitis
Encephalitis
Meningitis
Appendicitis
Gastric ulcer
Colitis
Pancreatitis
Gastritis
Headaches
Emphysema
Pneumonia
Bronchitis
Sinusitis
Asthma
Tuberculosis
Kidney disease
Bladder disease
Hepatitis
Jaundice
Strep throat
Mononucleosis
Rheumatic fever
Measles
Mumps
German measles
Scarlet Fever
Polio
Blood transfusion
Coagulation disorder
Anemia
Tobacco use
Anxiety
Depression
Suicide attempt
Eating disorder
Sleep difficulties
Drug abuse
Alcohol abuse
Recreational drug use
Venereal disease
Comments:
Page 7
Patient’s Name
23. MAJOR HOSPITALIZATIONS
REASON
DATE
24. HAVE YOU EXPERIENCED AN ALLERGIC OR UNUSUAL REACTION TO ANY
OF THE FOLLOWING DRUGS?
Penicillin
Other antibiotics
Sulfa
Local anesthesia
Aspirin
Opiates/codeine
Iodine
Other drugs: __________________
List other allergies (food, metals, etc.)
25. CURRENT PRESCRIPTION MEDICATIONS
List all medications now or recently used and amount.
1
5
2
6
3
7
4
8
26. LISTS ALL NON-PRESCRIPTION DRUGS
E.G. Laxatives, antacids, diet pills, food supplements, vitamins, etc.
1
4
2
5
3
6
27. HAZARD EXPOSURE
Are you or were you exposed to any of the following hazards at home, work or due to your hobbies?
Biologial hazards
Chemical hazards
Asbestos
Fumes
Heavy metals (e.g. lead, mercury)
Excesive noise
Radiation
Dust
Extremes of temperature
Other:
Page 8
Patient’s Name
28. MARITAL STATUS
Single
Married
Separated
Divorced
Widowed
29. CURRENT LIVING SITUATION
Living alone
Single parent
Living with other adult(s) and children
Living with other adult(s) with no children
30. WHAT KIND OF WORK HAVE YOU DONE MOST OF YOUR LIFE?
31. ARE YOU CURRENTLY EMPLOYED?
Yes
No
32. DENTAL HISTORY
Regular dental care
Emergency treatment only
Occasional dental care
Orthodontics
Wisdom tooth extractions
Treatment for jaw trauma/fracture
Tooth infection/abscess
Dentures
Orthographic Surgery
Periodontal surgery
Other Oral surgery
Bite adjustment
Night guard
Endodontic treatment
33. DENTURE USE (If applicable)
UPPER
LOWER
Is it a full or partial denture?
How long have you had the denture?
Do you wear it at night?
Are you satisfied with the denture?
If not, why not?
How do you clean the dentures?
34. ORAL HYGINE HABITS
Never Sometimes
1/Day
2/Day
Toothbrush use
Dental floss
Fluoride Gel/rinse
Mouthwash
3+/Day
Name of toothpaste: _________________
Yes
No
Does it contain Fluoride:
Name of mouthwash and/or fluoride rinse:
__________________________________
35. HAVE YOU HAD OR BEEN TOLD YOU HAD ANY OF THE FOLLOWING?
Gum disease (Pyoria, gingivitis, or periodontal disease)
Gum infection(s)
Geographic tongue
Thrush
Cold sores or fever blisters
Lichen planus
Page 9
B
S
DC
Bellevue Specialized
Dental Care
FINANCIAL ARRANGEMENTS
We would like to thank you for selecting our dental team to help you improve and maintain your dental
health. We enjoy what we do and are grateful for the opportunity to serve you.
We have adopted the following payment policy:
·
We accept cash, personal check, Visa, Master card, and debit cards.
·
Any patient (with insurance or not) that cancels his appointment with less than 48 hours will be
charged with $75.00. In case of a hygiene or perio appointment, there will be an additional charge of
$100.00 put into your account. There will be no exceptions. This charges, are not covered by any
insurance. This amount will have to be pay before we can continue with any existing dental treatment.
PLEASE NOTE: Any and all charges incurred for dental services provided are the responsibility of the
patient or guarantor of the patient, regardless of any type of third party (i.e. dental insurance). Any
account balance still owing after 60 days from date of service will be assessed a finance charge of 1.5%
monthly (18% annual) regardless of delayed, denied, or partial insurance coverage.
We will be happy to bill your dental insurance as a courtesy provided that you bring your insurance card
with you to your visit. You may also submit insurance claims yourself. We must emphasize that as dental
care providers, our relationship is with you, not your insurance company, with whom we have no legal
relationship. While the filing of insurance claims is a courtesy that we extend to our patients, all charges
are your responsibility from the date the services are rendered.
Please feel free to contact us and we will be happy to discuss any financial concerns you might have.
Dr. David Aronowitz and Staff
_______________________
Patient Signature
_______________
Date
Patient Name: _______________________________
David Aronowitz, D.D.S., M.S.D.
Bellevue Specialized Dental Care
SPECIAL CONSENT AND RELEASE FORM FOR TREATMENT
I understand that the expected results of said treatment cannot always be guaranteed. If I desire I can discuss, to my
satisfaction the following:
1. At BSDC Dr. David Aronowitz performs General Dentistry, Orofacial Pain/TMD and Oral Medicine and IV Sedation.
I fully understand that I must inform about my medical condition, including medications and allergies (Latex, Specific
medications, Sodium Bisulfite, certain foods) during the exam, and inform if any changes happened during my dental
treatment.. I fully understand that any omission of this information could represent a risk during and after my dental
treatment. If you are pregnant, nursing or want to become pregnant please inform us.
2. I understand that adverse drug reaction could happen to anyone, including a healthy patient. Local anesthetics are
drugs.
3. I provided information about ASTHMA, if any: Type (allergic/non-allergic), last asthma attack, medications, triggers,
etc., ANEMIA of any kind and METAGLOBULINEMIA. I will report Dr. Aronowitz upon arrival if I do not feel well, or
any important reason to postpone the treatment or to be re-scheduled.
4. If medical conditions are present I allow Dr. Aronowitz and associates to have a consultation with my primary physician,
order blood tests or other exams when needed. In severe medically compromised cases I consent that Dr. Aronowitz may
refer me to a hospital or hospital dental clinic.
5. I understand that reaction to stress, local anesthetics, medical condition, and medications are unique for each patient.
6. Medical emergencies in the dental office are rare but could include: Unconsciousness, respiratory distress, airway
obstruction, hyperventilation, bronchospasm, heart failure, altered consciousness, seizures, MI, CVA, drug related
emergencies, chest pain, cardiac arrest. In case I develop a life threatening condition after a dental procedure while at
home I should call 911, if the situation is not life threatening I was advise to call the office.
7. Local anesthetics will be used and although complications or adverse reactions are rare, these include: Needle breakage,
persistent anesthesia or paresthesia, facial nerve paralysis, trismus, soft-tissue injury, hematoma pain on injection, burning
on injection, infection, edema, sloughing of tissues, postanesthetic intraoral lesion, etc. If I don’t feel sick during or after
the use of anesthetics I should inform Dr. Aronowitz as soon as possible.
8. When oral sedation (Valium, Halcion, etc.), inhalation sedation (Nitrous Oxide) and IV conscious sedation is to be
used, I must be accompanied by a designated driver. The Dr. could deny treatment is designated driver is not present.
9. Vital signs are taken prior to any dental procedure involving local anesthetics and other drugs. If anything is abnormal
the Doctor will discuss it with me, my appointment might be reschedule and a possible medical consultation might be
needed.
10. Local anesthetics usage varies from patient to patient, type of procedure, area of injection, etc. Multiple attempts to
anesthetize an area might be needed. Duration varies from 30 minutes to 10 hours.
11. When an infection is present local anesthetics might not be 100% effective. Treatment might need to be re-scheduled,
and antibiotics and other medications will be prescribed.
12. Additional x-rays and clinic photographs might be necessary for documentation, insurance or treatment purposes,
etc.
13. If a procedure cannot be performed at the office you might be given a referral for a specific procedure (surgical
extractions, periodontal surgery, and complicated root canal treatments).
14. After selective procedures I will be provided with an emergency cellular phone number. I agree to use it ONLY for
emergencies related to that procedure. I should not use it for general questions, cancellations, financial statements, etc.
15. Questions concerning financial plans, insurance coverage, benefits, WILL NOT BE ANSWERED BY DR. ARONOWITZ.
They will be answered by the office manager or other staff members.
16. As a matter of office policy, at least 1staff members will be present with a patient.
17. I understand that no treatment will be performed until this consent is understood and signed. I understand that I am
free to withhold or withdraw consent to the proposed treatment at any time.
__________________________________________
Patient /guardian signature
__________________
Date
B
S
DC
Bellevue Specialized
Dental Care
15700 Bel-Red Road Bellevue, WA 98008
425.881.8448
Directions:
From WA-520 E:
Take the 148TH Ave. NE SOUTH exit
Merge onto 148TH Ave NE
Turn LEFT onto NE 24TH ST.
Turn LEFT onto BEL RED RD/
NE BELLEVUE REDMOND RD.
D
156TH N.E.
ON
ED
M
152ND
To
R
148TH N.E.
From I-90:
Take the 161ST Ave. SE/156TH Ave. SE/
150TH Ave. SE exit- exit number 11
Take the 156TH Ave. SE/150TH Ave.
SE ramp
Take the 156TH Ave. SE ramp
Turn LEFT onto SE Eastgate Way
Turn RIGHT onto 148TH Ave SE
Turn RIGHT onto BEL RED RD/
NE BELLEVUE REDMOND RD.
N.W. 24TH
SEARS
N.E. 20TH
NORTHUP WAY
GROUP
HEALTH
L-R
BE
ED
RO
AD