Dental Encounter
Syrian American Medical Society 2024
Date of Encounter
*
Patient Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Nationality
*
UNHCR / ID Number
*
Health | Dental History
Overall Health Questions
*
Yes
No
Are you in good general health?
Have you been evaluated by SAMS medical team
Have you been evaluated by SAMS Dental team
Medical Questions
*
Yes
No
Heart Disease
Pulmonary / Lung Disease (emphysema, COPD, etc..)
Kidney Disease (kidney stone, blood in urine etc...)
GI Disease (acid reflux, constipation, diarrhea
Neurologic (stroke, seizures, dementia, etc...)
Liver Disease
Do you have any other medical issues that have not been addressed above
Allergies
*
Medication
*
Do you smoke
*
Yes
No
How often do you consume alcoholic beverages?
*
Never
Once a month
2-3 times a week
Once a week
Everyday
Chief Complaint
*
Dental Questionnaire
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Yes
No
Do you have dental pain
Do you brush your teeth daily
Do you feel you have good teeth
Dental cleaning frequency
*
every 6 months
several years 1-3
once a year
over 3 years
never first time
Do your parents have any of their teeth
*
Have all their teeth
Have some of their teeth
Missing all their teeth
Dental Treatment
Upload Clinical and Xrays (Multiple Files) - only for referrals
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of
Treatment Summery
Treatment overview
*
Exam
Cleaning
Oral Cancer Screening
Flouride
Dental Hygiene
Smoking Cessation
Diet Counseling
Other
Number of Dental Extractions
*
Number Endo
*
Number of Filling
*
Number of SDF
*
Number of Restorative
*
Pulpotomy
*
Treatment Notes (Optional)
Prescriptions
*
List antibiotics | pain medication | others
Additional Treatment Needed / Referral (you can select more then one)
*
Hygeine
Restorative / Filling
Root Canal
Extractions
Maxillofacial Surgery
Medical Referral
Other
Provider's Name
*
Signature
*
Submit
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