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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