shorttdental.com - Implant Patient Questionnaire (West Branch)

General Dentistry

720 W Houghton Ave, West Branch MI, William A. Shortt, DDS, Therese F. Shortt, DDS, Chrisan J. Shortt, DDS, Juhi S. Shortt, DDS
Please complete prior to your appointment on:
Name:
Date:

MonthDayYear
Date
I have read the above pages and had the opportunity to ask any question to the dentist and am completely satisfied to proceed with the procedure.

By signing below, I am indicating that I agree with the statement above:
Signature of patient

Clear
Date

MonthDayYear
Date
For the following questions, select YES or NO, whichever applies. Your answers are for our records only and will remain confidential. These facts have a direct bearing on your dental health!
Sex
Height
Weight
Race
General Medical History
Are you in good general health?

YESNO
Has there been any change in your general health in the past year?

YESNO
My last physical examination was on (approximate date)

MonthDayYear
Date
Are you presently under a physician’s care?

YESNO
If yes, for what condition?
Please provide physician’s name and address:
Have you had any serious illness or operation?

YESNO
If yes, please list:
Have you been hospitalized/had a serious illness within the past 5 years?

YESNO
If yes, please provide the reason:
Cardiovascular System
Do you have the following? If yes, please check

Heart troubleHeart attackCoronary insufficiencyStrokeDamaged heart valveCongenital heart disease
Rheumatic heart disease, heart murmur?

YESNO
Chest pain after exertion?

YESNO
Shortness of breath after mild exercise?

YESNO
Do your ankles swell?

YESNO
Do you use extra pillows to sleep?

YESNO
Do you have a cardiac pacemaker?

YESNO
Do you have any blood pressure problems?

YESNO
If yes, check which one:

High blood pressureLow blood pressure
Central Nervous System
Do you HAVE or have you EVER had:

EpilepsyFainting spellsSeizuresEmotional disturbances
Do you follow any treatment for a nervous system disease?

YESNO
Respiratory System
Do you have a persistent cough or cold?

YESNO
Do you have or have you ever had tuberculosis?

YESNO
Is there any history of tuberculosis in your family?

YESNO
Do you have any sinusitis, sinus trouble?

YESNO
Do you have emphysema, chronic bronchitis, asthma?

YESNO
Digestive system
Do you have any stomach ulcers?

YESNO
Do you have, or have you ever had?

HepatitisJaundiceLiver Disease
Have you ever vomited blood?

YESNO
Do you have any diarrhea?

YESNO
Endocrine System
Do you have diabetes?

YESNO
Is it

UncontrolledControlled?
Does anyone in your family have diabetes?

YESNO
Do you urinate more than six times a day?

YESNO
Are you thirsty very often or do you have a dry mouth?

YESNO
Hematogenic System
Do you hae anemia, sickle cell disease, blood disorder?

YESNO
Is there any family history of blood disorders?

YESNO
Are you hemophilic?

YESNO
Have you had abnormal bleeding after any surgery, extraction, or trauma?

YESNO
Have you ever had a blood transfusion?

YESNO
Immunodeficiency problem?

YESNO
Allergies

Are you allergic to or have you acted adversely to:

	YES	NO
Local anesthetics?
Antibiotics, penicillin, sulfa drug?
Barbiturates, sedatives or sleeping pills?
Aspirin?
Iodine?
Codeine or other narcotics?
Latex?

Other allergies?

YESNO
Please Specify:
Do you have asthma or hay fever?

YESNO
Do you have or have you ever had hives or skin rash?

YESNO
Genitourinary System

Do you have or have you ever had:

	YES	NO
Kidney trouble?
Syphilis, gonorrhea?

Bones and Joints

Do you have:

	YES	NO
Arthritis?
Inflammatory rheumatism?
Bone infection?
Osteoporosis?

Other

Do you have or ever had:

	YES	NO
Tumor or malignancy?
Chemotherapy, or Radiation therapy?

Do you have or have you ever had any disease, condition, or problem NOT listed above that you think we should know about?

YESNO
If yes, please explain below:
Are you regularly exposed to x-rays or ANY other ionizing radiation or toxic substances?

YESNO
Are you wearing, or do you wear contact lenses?

YESNO
Do you drink alcohol?

YESNO
If yes, how much and how often?
Do you smoke tobacco?

YESNO
If yes, how much and how often?
Do you use oral tobacco?

YESNO
If yes, how much and how often?
Your Medications

Are you taking any of the following medications:

	YES	NO
Antibiotics or sulfa drugs?
Anticoagulant, blood thinning agents?
Tranquilizers?
Iodine?
Codeine or other narcotics?
Steroids?

Medication list:
Please provide a list of any type of medication you are currently taking as well as the dosage. Please include prescription AND over the counter medications.

A little more about your medical history:

	YES	NO
Are you pregnant?
Are you nursing?
Do you have any problems associated with your menstrual period?
Are you taking oral contraceptives?
Are you undergoing hormonal therapy?

Dental History
What is your chief dental complaint?
Are you experiencing any discomfort or pain at this time?

YESNO
Are you satisfied with the appearance of your teeth?

YESNO
Are you able to eat and chew foods satisfactorily?

YESNO
Do you have headaches, earaches, or neck pain?

YESNO
Do you frequently experience sinus problems?

YESNO
Have you had any serious trouble associated with any previous dental treatment?

YESNO
If yes, please explain:
Other conditions not listed:

General dental responsibility and consent statement:
I hereby authorize and request the performance of:
*** You must return to our office at regular intervals for examination and service to maintain the implant as you would your normal teeth. If you do not do this, difficulties may arise, resulting in the loss of the implant(s). Smoking and/or excessive alcohol consumption is a deterrent to a successful implant and may set your implant up for failure. Under such circumstances, the responsibility would be yours should the implant fail or should it need additional procedures.
please initial here
I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or their supervised staff for diagnostic purposes and/or dental treatment. These records may include study models, photographs, radiographs (x-rays), and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I also understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to modify the treatment. In such a case, I will be informed of the need for additional treatment, and any fee modification.

By signing below, I agree to the above statement AND agree to the best of my knowledge, the information I have provided in this form is accurate
Signature of patient/guardian

Clear
Date

MonthDayYear
Date
Signature of witness

Clear
Date

MonthDayYear
Date
Math Challenge*
Should be Empty:

	Always	Occasionally
Headache
Teeth grinding/clench
Gagging reflex
Difficulty swallowing
Mouth sores
Difficulty chewing food
Dizziness, ringing in ears
Numbness in lower lip
Difficulty speaking
Digestive disorders
Nutritional Disorders

General Dentistry

General Medical History

Cardiovascular System

Central Nervous System

Respiratory System

Digestive system

Endocrine System

Hematogenic System

Allergies

Genitourinary System

Bones and Joints

Other

Your Medications

Medication list:

Dental History

Patient dental evaluation

About your natural teeth

About your dentures/Partials

General dental responsibility and consent statement: