estheticdentist.com
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Patient Information Form
We have made this form available for your convenience, and to reduce the amount of paperwork during your visit to the Fitzgerald Dental Center. This form may vary depending on the answers you select, so please read each question carefully. If you have any questions or concerns please call our office at (469) 656-4526.
Today's Date
*
MM
DD
YYYY
Please enter today's date in numeric form.
Are you completing this form on behalf of someone else?
*
Yes
No
Your Name
*
First
Last
What is your relationship to the patient?
*
Patient Health History
Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, can have an important interrelationship with your oral health and the dentistry you will receive. Thank you for answering the following questions. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Full Name
*
Prefix
First
Last
Suffix
Preferred Name
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Home Phone
*
Please enter a 10 digit phone number with no special characters or symbols.
Work Phone
Please enter a 10 digit phone number with no special characters or symbols.
Cell Phone
Please enter a 10 digit phone number with no special characters or symbols.
Gender
*
Female
Male
Date of Birth
*
MM
DD
YYYY
Please enter your date of birth in numeric form.
Age
*
Drivers License State
*
Height
This information may be required for some procedures.
Weight
This information may be required for some procedures.
E-mail Address
*
Employer
*
Marital Status
*
Single
Committed Relationship
Married
Widowed/Divorced
Other
Spouse's Name
*
Partner's Name
*
How were you referred to our practice?
Emergency Contact Information
Emergency Contact Name
*
First
Last
Emergency Contact Phone Number
*
Please enter a 10 digit phone number with no special characters or symbols.
Relationship to Patient
*
Medical Information
Please select yes or no to indicate if you have or have not had any of the following diseases or problems.
Are you now under the care of a physician?
*
Yes
No
Are you in good health?
*
Yes
No
Physician Name
*
Physician Phone
*
Physician Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Has there been any chance in your general health within the past year?
*
Yes
No
Date of last physical exam
*
MM
DD
YYYY
Please enter the date of your last physical exam in numeric form.
What condition is being treated?
*
Have you had a serious illness, operation or been hospitalized in the past 5 years?
*
Yes
No
What was the illness or problem?
*
Pre-Medication
Antibiotic pre-medication may be required prior to dental treatment for the following conditions only.
Any form of vascular stints
*
Yes
No
Artificial (prosthetic) heart valve
*
Yes
No
Previous infective endocarditis
*
Yes
No
Damaged valves in transplanted heart
*
Yes
No
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
*
Yes
No
Joint Replacement - Orthopedic total joint (hip, knee, elbow, finger) within the past 2 years
*
Yes
No
Name of physician or dentist making recommendation
*
Why were antibiotics recommended?
*
Physician or Dentist Phone
*
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
*
Yes
No
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?
*
Yes
No
Date Treatment began
*
MM
DD
YYYY
Please enter the date treatment began in numeric form.
Congenital heart disease (CHD)
*
Yes
No
Unrepaired, cyanotic CHD
*
Yes
No
Repaired (completely) in last 6 months
*
Yes
No
Allergies
Are you allergic to or have you had a reaction to: To all yes responses specify type of reaction.
Local anesthetic
*
Yes
No
Aspirin
*
Yes
No
Specify type of reaction to Local anesthetic
*
Specify type of reaction to Aspirin
*
Barbiturates, sedatives, sleeping pills
*
Yes
No
Sulfa drugs
*
Yes
No
Specify type of reaction to Barbiturates, sedatives, sleeping pills
*
Specify type of reaction to Sulfa drugs
*
Penicillin or other antibiotics
*
Yes
No
Codeine or other narcotics
*
Yes
No
Specify type of reaction to Penicillin or other antibiotics
*
Specify type of reaction to Codeine or other narcotics
*
Metals
*
Yes
No
Latex (rubber)
*
Yes
No
Specify type of reaction to Metals
*
Specify type of reaction to Latex (rubber)
*
Iodine
*
Yes
No
Hay fever/seasonal
*
Yes
No
Specify type of reaction to Iodine
*
Specify type of reaction to Hay fever/seasonal
*
Animals
*
Yes
No
Food
*
Yes
No
Specify type of reaction to Animals
*
Specify type of reaction to Food
*
Other
*
Yes
No
Specify type of reaction to Other
*
Medical Conditions
Please indicate if you have or have not had any of the following diseases or problems.
Abnormal bleeding
*
Yes
No
Anemia
*
Yes
No
Angina
*
Yes
No
Arteriosclerosis
*
Yes
No
AIDS or HIV infection
*
Yes
No
Arthritis
*
Yes
No
Asthma
*
Yes
No
Autoimmune disease
*
Yes
No
Bronchitis
*
Yes
No
Cancer/Chemotherapy
*
Yes
No
Radiation Treatment
*
Yes
No
Cardiovascular disease
*
Yes
No
Chest pain upon exertion
*
Yes
No
Chronic pain
*
Yes
No
Congestive heart failure
*
Yes
No
Damaged heart valves
*
Yes
No
Diabetes Type I or II
*
Yes
No
Eating disorder
*
Yes
No
Epilepsy
*
Yes
No
Emphysema
*
Yes
No
Excessive urination
*
Yes
No
Fainting spells or seizures
*
Yes
No
Gastrointestinal diease
*
Yes
No
Glaucoma
*
Yes
No
G.E. Reflux/persistent heartburn
*
Yes
No
Hemophilia
*
Yes
No
Heart murmur
*
Yes
No
High blood pressure
*
Yes
No
Heart attack
*
Yes
No
Kidney problems
*
Yes
No
Low blood pressure
*
Yes
No
Malnutrition
*
Yes
No
Mitral valve prolapse
*
Yes
No
Neurological disorders
*
Yes
No
Night sweats
*
Yes
No
Other congenital heart defects
*
Yes
No
Persistent swollen glands/neck
*
Yes
No
Rheumatic fever
*
Yes
No
Rheumatic heart disease
*
Yes
No
Rheumatoid arthritis
*
Yes
No
Sleep disorder
*
Yes
No
Systemic lupus erythematosus
*
Yes
No
Sinus trouble
*
Yes
No
Tuberculosis
*
Yes
No
Ulcers
*
Yes
No
Thyroid problems
*
Yes
No
Stroke
*
Yes
No
Severe headaches/ migraines
*
Yes
No
Severe or rapid weight loss
*
Yes
No
Sexually transmitted disease
*
Yes
No
Blood transfusion
*
Yes
No
Hepatitis, jaundice or Liver disease
*
Yes
No
Date of Blood transfusion
*
MM
DD
YYYY
What type?
*
Mental health disorders
*
Yes
No
Recurrent Infections
*
Yes
No
If yes, specify:
*
Type of infection:
*
Health Information
Do you use tobacco?
*
Yes
No
Do you have a history of chemical dependency including alcohol?
*
Yes
No
Select which one applies
*
Smoking
Snuff
Chew
Bidis
If yes, how much do you typically drink in a week?
*
Are you contemplating stopping?
*
Yes
No
Women Only
Are you pregnant?
*
Yes
No
Number of weeks?
*
Taking birth control pills or hormonal replacement?
*
Yes
No
Nursing?
*
Yes
No
Medication Information
Are you taking or have you recently taken any prescription or over the counter medicine(s), including vitamins, natural or herbal preparations, and/or diet supplements?
*
Yes
No
Please list all medications including vitamins, natural or herbal preparations and/or diet supplements, and the reason for which they are being taken:
*
Do you have any disease, condition, or problem not listed above that you think we should know about?
*
Yes
No
Please explain:
*
Note to Patient:
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. 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.
Signature of Patient, Parent, or Legal Guardian:
Date Signed:
Patient Dental Information
Are you currently experiencing any dental discomfort/problem?
*
Yes
No
Please explain:
*
Name of last Dentist:
*
City/State of last Dentist
*
Date of your last dental visit:
*
What was done during your last dental visit?
*
When was your last dental cleaning?
*
Date of last dental x-rays:
*
Are you interested in a comprehensive dental life plan evaluation or in basic dental care maintenance?
*
Dental History
Please select the most accurate response.
How often do you brush?
*
What kind of toothbrush do you use?
*
Manual
Electric
Battery
What brand is it?
*
Do you floss your teeth?
*
Yes
No
How often do you floss?
*
Occasionally
Daily
A few days a week
A few days a month
I do not floss
Do you use mouthwash?
*
Yes
No
Do you drink bottled or filtered water?
*
Yes
No
What brand/kind?
*
How often?
*
Daily
Weekly
Occasionally
Is your home water supply fluoridated?
*
Yes
No
Don't know
Have you ever had orthodontic (braces) treatment?
*
Yes
No
Have you had any periodontal (gum) treatments?
*
Yes
No
When?
*
Please explain what and when:
*
Orthodontist Name:
*
Do you wear dentures or partials?
*
Yes
No
Would you be Interested or contemplating dental implant(s)?
*
Yes
No
Have you had any problems associated with previous dental treatment?
*
Yes
No
Have you ever had a serious injury to your head or mouth?
*
Yes
No
Please explain:
*
Please explain:
*
Do you experience any of the following problems or symptoms?
Teeth sensitive to hot
*
Yes
No
Teeth sensitive to cold
*
Yes
No
Teeth sensitive to sweets
*
Yes
No
Teeth sensitive to pressure
*
Yes
No
Bleeding gums
*
Yes
No
Mouth breathing
*
Yes
No
Dry mouth
*
Yes
No
Burning sensation on the tongue
*
Yes
No
Tender or swollen gums
*
Yes
No
Halitosis/ Bad breath
*
Yes
No
Mouth ulcers
*
Yes
No
Blister on lips and mouth
*
Yes
No
Lip or cheek biting
*
Yes
No
Loose teeth or broken filling
*
Yes
No
Chew on one side of the mouth
*
Yes
No
Food or floss catches between teeth
*
Yes
No
Pain around the ear or neck
*
Yes
No
Clench or grind teeth
*
Yes
No
Jaw pain or tiredness
*
Yes
No
Clicking, popping or discomfort in the jaw
*
Yes
No
How often?
*
Esthetic Evaluation
How happy are you with the overall appearance of your teeth and smile?
*
Not happy
Happy
Is there anything in particular about your teeth/smile that you would like to change/improve?
*
If not explain why:
*
Are you happy with the alignment of your teeth?
*
Yes
No
Do you have spaces in between your teeth that you don't like?
*
Yes
No
If not explain why:
*
If yes explain:
*
Would you be interested in orthodontic treatment?
*
Yes
No
Have you ever had your teeth whitened or bleached?
*
Yes
No
Please explain:
*
If yes, when and what kind of whitening have you had?
*
Do your teeth have unattractive staining?
*
Yes
No
Do you like the color of your teeth?
*
Yes
No
What kind of staining?
*
Coffee, Tea, Wine
Silver filling stain
Discolored fillings
Tetracycline stains
Tobacco stain
Other
If Other, please explain:
*
Do you think your teeth are attractive?
*
Yes
No
What is unattractive about your teeth?
*
Chipped
Overlapping
Protruding
Excessively worn
Artificial looking
Other
If Other, please explain:
*
Do you like the shape of your teeth?
*
Yes
No
Do you think your gums are attractive?
*
Yes
No
If no, please explain:
*
Do you have any bridge or missing tooth/teeth that you woud like to replace by dental implant(s)?
*
Yes
No
Is there any existing fillings or dental work that you consider unattractive and would like to have replaced?
*
Yes
No
If yes, please explain:
*
If yes, please explain:
*
The Fitzgerald Dental Center would like to Thank You for completing the online medical information form. This will greatly reduce the amount of paperwork that must be completed during your office visit.