Sedationdentalcare.net

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. 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.
Home Phone: Include area code Business/Cell Phone: Include area code If you are completing this form for another person, what is your relationship to that person? Do you have any of the following diseases or problems:
(Check DK if you Don’t Know the answer to the question) Yes No DK
Persistent cough greater than a 3 week duration Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dental Information For the following questions, please mark (X) your responses to the following questions. Do your gums bleed when you brush or floss? Are your teeth sensitive to cold, hot, sweets or pressure? Do you have any clicking, popping or discomfort in the jaw? Does food or floss catch between your teeth? Do you have sores or ulcers in your mouth? Have you had any periodontal (gum) treatments? Have you ever had orthodontic (braces) treatment? Do you participate in active recreational activities? Have you had any problems associated with previous dental Have you ever had a serious injury to your head or mouth? Do you drink bottled or filtered water?If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Are you currently experiencing dental pain or discomfort? What is the reason for your dental visit today? Medical Information Please mark (X) your response 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? Have you had a serious illness, operation or been Are you taking or have you recently taken any prescription Has there been any change in your general health within If so, please list all, including vitamins, natural or herbal preparations Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. (Check OK if you Don’t Know the answer to the question)
Do you use controlled substances (drugs)? Are you taking, or have you taken, any diet drugs such as Do you use tobacco (smoking, snuff, chew, bidis)? Pondimin (fenflluramine), Redux (dexphenfluramine) or If so, how interested are you in stopping? phen-fen (fenflluramine-phentermine combination)? (Circle one) VERY / SOMEWHAT / NOT INTERESTED Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) If yes, how much alcohol did you drink in the last 24 hours? If yes, how much do you typically drink in a week? Since 2001, were you treated or are you presently scheduled WOMEN ONLY Are you:
to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma Taking birth control pill or hormonal replacement? Date Treatment began:
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Date:
Allergies - Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.
Barbiturates, sedatives, or sleeping pills Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Name of physician or dentist making recommendation? Do you have any disease, condition, or problem not listed above that you think I should know about? 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.
FOR COMPLETION BY DENTIST

Source: http://www.sedationdentalcare.net/fp/pdfs/MedHistory.pdf