Online Patient Form

Name

First Name Middle Name Last Name
This is a health history update. Please indicate anything regarding your health (Medical and Dental) that has changed since your last visit to our office. Thank you.
Date of Last Dental Treatment was?
Why did you select our practice?
What Is The Reason For Today’s Visit?
Do You Have Questions Or Concerns?
Have Your Teeth Embarrassed You In The Last Year?
Do You Love Your Smile?
Is There Anything You Would Like To Change About Your Smile?
Has Your Health Changed During The Past Six Months?
Who May We Thank For Your Referral?
Medical/Dental History
Do you presently have or have had pain or discomfort in the mouth, face or jaws?

Yes No
Do your gums bleed at any time?

Yes No
Do you have aching or sensitive teeth?

Yes No
Have you had an injury to your face or jaw?

Yes No
Have you had serious trouble associated with any previous dental treatment?

Yes No
Do you feel nervous or uneasy about having dental treatment?

Yes No
Have you been a patient in a hospital during the past two years?

Yes No
If Yes, Reason:
Have you been under the care of a medical doctor during the past two years?

Yes No
If Yes, Reason:
Do you use tobacco products?

Yes No
Do you drink alcoholic beverages?

Yes No
How many per week:
Do you use recreational or street drugs?

Yes No
Are you currently taking, or have you taken within the past two years, any prescription or non-prescription drugs?

Yes No

If Yes, Please List:

DRUG

DOSE/FREQUENCY

REASON FOR TAKING

Do you have any allergies (i.e. itching, rash, swelling on hands, eyes, or are you made sick by metals, jewelry, latex rubber, aspirin, penicillin, codeine, or any drugs, foods, medication?

Yes No
If Yes, Please List:
Have you ever had excessive bleeding requiring special treatment?

Yes No
When you walk upstairs or take a walk, do you ever have to stop because of chest pain?

Yes No
Do your ankles swell during the day?

Yes No
Do you use more than two pillows to sleep?

Yes No
Have you lost or gained more than 10 pounds in the last year?

Yes No
Do you wake up short of breath?

Yes No
Are you on a special diet?

Yes No
Women: Are you pregnant now?

Yes No
Women: Are you currently using a prescription-type contraceptive?

Yes No
Do you snore, clench, or grind your teeth?

Yes No
Does your jaw click when you open your mouth?

Yes No
Have you previously had orthodontic treatment?

Yes No
Do you wear a retainer?

Yes No
Do you medicate before dental treatment?

Yes No
Do you have any disease, condition, or problem not listed?

Yes No
If Yes, Please List:
Please Indicate Any of The Following You Are Now Experiencing
HEAD/FACE -

Forehead headaches Temporal headaches Tension headaches Migraine-type headaches Sinus headaches Back of head headaches Scalp tender to touch
NECK -

Lack of mobility Stiffness Neck pain Tired/sore neck muscles Shoulder pain Back pain Arm/finger pain or numbness
JAW-

Jaw pain Jaw joint pain Clicking/popping in jaw joint(s) Grinding sound in jaw joint(s) Pain in cheek muscles Uncontrollable jaw movements Jaw locks open/shut Deviation of jaw to one side
EARS -

Ear pain without infection Decreased hearing Clogged/stuffy feeling in ear(s) Itchy feeling in ear(s) Ringing/buzzing in ear(s) Dizziness Balance problems
EYES -

Pain in/around eyes Bloodshot eyes Sensitivity to light Tearing of eyes Blurred vision Pressure behind eyes Dark circles under eyes
MOUTH -

Abnormal opening Limited opening Bad bite Missing teeth Clenching/grinding teeth Mouth discomfort Inability to find bite Mouth discomfort Sour or foul taste in mouth
THROAT -

Difficulty swallowing Feeling of foreign object in throat Sore throat without infection Voice changes Laryngitis Frequent coughing or clearing
NASAL -

Sinus pain Sinus problems Post-nasal drainage Allergies
SLEEP -

Snoring Sleep apnea Have been told I snore Have been told I stop breathing Have awoken gasping for air
What Are The Chief Complaints For Which You Are Seeking Care.

Please Order Complaints By Number (1=Most Important, 10=Least)
Throat Pain
Back Pain
Pain Behind Eyes
Visual Disturbance
Jaw Clicking
Dizziness
Pain When Chewing
Sinus Congestion
Jaw Joint Noise
Ear Pain
Ringing In Ears
Muscle Twitching
Jaw Locking
Facial Pain
Shoulder Pain
Ear Congestion
Jaw Pain
Headaches
Limited Mouth Opening
Fatigue
Inability To Open Mouth
Have You Taken Fosamax, Boniva, Or Any Other Bisphosphonate Drug In The Past?

Yes No
Please List Other Health Providers You Are Currently Seeing

If Yes, Please List:

PRACTITIONER

SPECIALTY

TREATMENT RECEIVED

APRX DATE

The Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytime sleepiness.

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = Would Never Doze

1 = Slight Chance Of Dozing

2 = Moderate Chance Of Dozing

3 = High Chance Of Dozing

Situation:
Siting and reading
Watching television
Sitting inactive in a public place (e.g. theatre, meeting)
As a car passenger for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic
TOTAL SCORE
Please Indicate Any Medications/Substances Which Have Caused An Allergic Reaction
Antibiotics Aspirin Barbiturates Codeine Iodine Latex Local Anesthetic Metals Penicillin Plastics Sedatives Sleeping Pills Sulfa Drugs
Please List All Medications Currently Being Taken
Antibiotics Anticoagulants Barbiturates Blood Thinners Codeine Cortisone Diet Pills Heart Medication Insulin Muscle Relaxants Nerve Pills Pain Medication Sleeping Pills Sulfa Drugs Tranquilizers
Please Update The Following Medical/Dental History
AIDS or HIV antibody:
Artificial Joint:
Artificial Heart Valve:
Adenoids Removed:
Tonsils Removed:
Anemia:
Angina (Chest Pain):
Arteriosclerosis:
Asthma:
Autoimmune Disorder:
Bleeding Easily:
High Blood Pressure:
Low Blood Pressure:
Bruising Easily:
Cancer:
Chemotherapy:
Chronic Fatigue:
Cold Hands/Feet:
Cold Sores/Fever Blisters:
Current Pregnancy:
Depression:
Diabetes:
Difficulty Focusing:
Dizziness:
Emphysema:
Epilepsy/Seizures:
Excessive Thirst:
Fluid Retention:
Frequent Cough:
Frequent Illness:
Frequent Stress:
General Anesthesia:
Glaucoma:
Gout:
Hay Fever:
Hearing Impairment:
Heart Murmur:
Heart Disorder:
Heart Pacemaker:
Heart Palpitations:
Heart Valve Repl.:
Hemophilia:
Hepatitis:
Hypoglycemia:
Immune Disorder:
Injury To Face:
Injury To Neck:
Injury To Mouth:
Injury To Teeth:
Insomnia:
Intestinal Disorder:
Irritable Bowel:
Jaw Joint Surgery:
Kidney Problems:
Liver Disease:
Meniere’s Disease:
Menstrual Cramps:
Multiple Sclerosis:
Muscle Aches:
Muscle Tremors:
Muscle Cramps:
Muscular Dystrophy:
Need Pillow At Night:
Nervous Irritability:
Nervousness:
Neuralgia:
Osteoporosis:
Parkinson’s Disease:
Poor Circulation:
Prior Orthodontics:
Psychiatric Care:
Radiation Treatment:
Rheumatic Fever:
Rheumatoid Arthritis:
Scarlet Fever:
Shortness Of Breath:
Sickle Cell Disease:
Sinus Problems:
Skin Disorders:
Slow Healing Sores:
Speech Difficulty:
Stroke:
Stomach problems/ Ulcers:
Swollen Joints:
Frequent Colds:
Freq Sore Throat:
Freq Ear Infection:
Thyroid Disease:
Tuberculosis:
Tubes In Ears:
Tumors:
Urinary Disorders:
Wisdom Teeth Extraction:
Fosamax Use:
Bisphosphonate Drugs

***If you take any of the following, let our staff know immediately
Please read the list below and mark the appropriate choice.

Actonel (risendronate) Actonel Plus Ca (risendronate + Ca) Aredia (pamidronate) Boniva (ibandronate) Didronel (etidronate) Fosamax (alendronate) Fosamax Plus D (Alendronate + Vit. D) Reclast (zoledronic) Skelid (tiludronte) Zometa (zoledronic) I do not take any of the drugs listed above.
'Jaw osteonecrosis seems to be associated with trauma. Most cases occur after extractions and are located near the mylohyoid ridge. Of those not associated with extractions, they are commonly associated with dentures or exostoses. Chronic periodontitis also increases the risk of osteonecrosis development. Osteonecrosis will appear as exposed yellow-white bone. Sinus tracts and painful ulcers may also be present. (1)'

Adult/Child Health History
Is the patient an Adult or a Child?

Adult Child
*

I Certify That The Above History Is True And Correct To The Best Of My Knowledge.
Signature *

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Date *

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