AVENUE FAMILY DENTAL PATIENT HISTORY QUESTIONNAIRE

MEDICAL ALERT:
(for doctor use)



Name: Date of Birth:
Address: Phone:
postal code Cell:
Physician: Specialist:
Person Responsible for Treatment: Self Other:
When was your last cleaning?
When were xrays last taken? Would you like us to request those xrays?
Name of previous Dentist or Dental Office
Insurance Carrier: Group: ID: Dept: Today’s Date:
Who Referred you to our office?
Your Occupation:
Emergency Contact Name: Daytime Phone:
THE FOLLOWING INFORMATION IS REQUIRED TO ENABLE US TO PROVIDE YOU WITH THE BEST POSSIBLE DENTAL CARE. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
• Have you been treated for any medical condition within the past year?
YES NO NOT SURE
• Have there been any changes in your general health in the past year?
YES NO NOT SURE
• Have you been seeing a dentist regularly? When was your last dental visit?
YES NO NOT SURE
• When was your last dental cleaning? When were your last dental x-rays?
YES NO NOT SURE
• Are you currently pregnant or breastfeeding?
YES NO NOT SURE
• Have you ever been advised to take antibiotics before dental visits?
YES NO NOT SURE
• Are you nervous during dental treatment?
YES NO NOT SURE
• Have you been in a motor vehicle accident or experienced any blows to the jaws?
YES NO NOT SURE
• Have you ever had any surgery to your jaw or jaw joints? Including dental implants,
Periodontal surgery & Extractions.
YES NO NOT SURE
• Have you had prior orthodontic (braces or Invisalign) treatment?
YES NO NOT SURE
• How often do you brush your teeth?
YES NO NOT SURE
• How often do you floss your teeth?
YES NO NOT SURE
• Are you currently on any type of blood thinner ?
YES NO NOT SURE
• Have you ever taken any type of osteoporosis medication?
YES NO NOT SURE
AIDS/HIV POSITIVE
ALCOHOLISM
ALLERGIES (see below)
ANEMIA
ANXIETY
ARTHRITIS
ARTIFICIAL VALVE
ARTIFICIAL JOINTS
ASTHMA
BACK PROBLEMS
BLOOD DISEASE
CANCER
CHEMOTHERAPY
CIRCULATION ISSUES
INTESTINAL ISSUES
JAW PAIN
CORTISONE SHOTS
COUGH-PERSISTENT
COUGH-BLOOD
COUGH-POST NASAL
DEPRESSION
DIABETES
CHEST PAIN/ANGINA
STEROID THERAPY
NECK/C-SPINE ISSUES
DRY MOUTH
EPILEPSY
FAINTING
GERD/ REFLUX
GLAUCOMA
HEADACHES
HEARING LOSS
HEART PROBLEMS
HEMOPHILIA
HERPES
HEPATITIS A B C
HIGH BLOOD PRESSURE
IMMUNE ISSUES
IMPLANTS
SWELLING OF FEET/ETC
THYROID ISSUES
KIDNEY DISEASE
LEUKEMIA
LIVER DISEASE
MEMORY LOSS
MITRAL VALVE PROLAPSE
PACEMAKER
OSTEOPOROSIS
SNORING
TINNITUS (RINGING IN EARS
MURMUR - HEART VALVE
NERVOUS PROBLEMS
PSYCHIATRIC CARE
RADIATION TREATMENT
RESPIRATORY DISEASE
RHEUMATIC FEVER
SEIZURES
SHINGLES
SHORTNESS OF BREATH
SINUS PROBLEMS
SKIN RASH
STROKE
SUBSTANCE ABUSE
TOBACCO USE
TONGUE THRUST
TUBERCULOSIS
ULCERS/COLITIS
•PLEASE LIST YOUR KNOWN ALLERGIES (INCLUDING ADVERSE REACTIONS):
LOCAL ANESTHETIC
ASPIRIN
PENICILLIN
CODEINE
SULFA
LATEX
TYLENOL
IBUPROFEN
OTHERS
•PLEASE LIST ANY MEDICATIONS / VITAMINS / HERBAL SUPPLEMENTS YOU ARE TAKING:
•PLEASE CHECK IF YOU HAVE ANY PROBLEMS WITH THE FOLLOWING:
BAD BREATH PERIODONTAL POCKETING
BLEEDING, SENSITIVE GUMS RECESSION
CLICKING OR POPPING IN JAW SENSITIVITY TO COLD
FOOD TRAPPED BETWEEN TEETH SENSITIVITY TO HOT
GRINDING OR CLENCHING TEETH SENSITIVITY TO SWEET
LOOSE TEETH SORENESS ON BITING
BROKEN TEETH OR FILLINGS STAINING
ULCERS/SORES IN MOUTH
AUTHORIZATION:
I HAVE REVIEWED ALL OF THE ABOVE INFORMATION AND ANSWERED ALL THE QUESTIONS TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THIS INFORMATION WILL BE USED TO DETERMINE THE DENTAL TREATMENT I RECEIVE AT THIS OFFICE AND MAY BE SHARED WITH OTHER MEDICAL OFFICES ONLY AS NECESSARY. I WILL NOTIFY THE OFFICE SHOULD ANY INFORMATION CHANGE IN THE FUTURE.
I ALSO UNDERSTAND THAT SHOULD MY INSURANCE COMPANY NOT PAY ANY PART OF THE FEES SUBMITTED, FOR WHATEVER REASON, I AM RESPONSIBLE TO PAY THE OUTSTANDING AMOUNT IN FULL, IMMEDIATELY UPON RECEIPT OF NOTIFICATION. I HEREBY ASSIGN MY BENEFITS PAYABLE FROM CLAIMS SUBMITTED ELECTRONICALLY TO DRS EVANS, WEBSTER OR KOLSUN, AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER.
Date: PATIENT SIGNATURE: