Client Intake Patient Information Name: Birthday: Social Security: Home Phone Number: Cell Phone Number: Address: City: State: Zip Code: Email Address: Check Appropriate: MinorSingleMarriedDivorcedOther Patient’s Employer: Work Phone Number: Business Address: City: State: Zip Code: Person to contact in case of emergency: Phone Number: Responsible Party Name of person responsible for this account: Relationship to patient: Address: Home Phone Number: Driver’s License Number: Birthdate: SSN: Employer: Work Phone Number: Referral Information Were you referred by one of our patients? YesNo If yes, whom may we thank? If no, how did you find us? Insurance Information Name of insured: D.O.B: SSN: Relationship to Patient: Dental Insurance Company Name: Policy Number: Medical Insurance Company Name: Policy Number: HIPPA Acknowledgement I have read and been offered a copy of the HealthDent Dental Notice of Privacy Practice. Printed Name: Patient Signature Patient Information Your Physician: Office Phone: Date of Last Exam: 1. Are you under medical treatment right now? YesNo 2. Have you ever been hospitalized for any surgical operation or serious illness? YesNo 3. Are you taking any medications? YesNo If yes, what medications are you taking? 4. Have you ever been prescribed antibiotics prior to dental treatment? YesNo 5. Have you ever taken phen-phen? YesNo 6. Are you allergic to or had any reactions to the following? Local Anesthetic YesNo Penicillin or other Antibiotics YesNo Codeine YesNo Latex YesNo Other YesNo Do you snore YesNoMaybe 7. Do you have or have had any of the following? Heart Disease YesNo Sleep Apnea YesNo Cardiac Pacemaker YesNo Heart Murmur YesNo Angina YesNo Coumadin Therapy YesNo High Blood Pressure YesNo Prolonged Bleeding YesNo Anemia YesNo Joint Replacement/ Implant YesNo Sexual Transmitted Disease YesNo Rheumatic Fever YesNo Asthma YesNo Emphysema YesNo Hay Fever/ Pollen YesNo Tuberculosis YesNo Fainting/ Seizures YesNo Epilepsy/ Convulsions YesNo Diabetes YesNo Kidney Disease YesNo Thyroid Problem YesNo Cancer YesNo Arthritis YesNo Hepatitis YesNo Jaundice YesNo Down syndrome YesNo Alzheimer’s YesNo Aids/ HIV Infection YesNo Stroke YesNo Apthous Ulcers YesNo Cold Sores YesNo Patient Dental History Do your gums bleed while you are brushing or flossing? YesNo Are your teeth sensitive to hot or cold liquids/ foods? YesNo Do you have or have you had gum disease? YesNo Do you feel pain to any of your teeth? YesNo Have you ever experienced any of the following problems in your jaw? YesNo Do you clench or grind your teeth? YesNo Clicking or popping? YesNo Pain (joint, ear, side of face)? YesNo Difficulty in chewing? YesNo Do you have frequent headaches? YesNo Patient Signature: Date: Do you have difficulty getting numbed? YesNo Are you apprehensive of dental treatment? YesNo Have you ever had any prolonged bleeding following extraction? YesNo Would you be interested in whitening your teeth? YesNo Do you like the appearance if your teeth, your smile? YesNo If not, please explain below: When was your last exam and cleaning done? YesNo Doctor’s Signature: Date: At HealthDent Dental we care not only for your teeth but for your overall health as well. Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health of the following patients. Please take a moment to review the following and respond to those that apply to you. Yes Tobacco User Yes Diabetes Yes Family History of gum disease Yes Stress Yes Rheumatoid Arthritis Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease (and since gum disease only worsens that risk) it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease. Yes Current Tobacco user → What form? (cig, pipe, chew, etc.) How much/ day? For how long? Yes Previous Tobacco user → When did you quit? Diabetes is a well- known risk factor for gum disease. Research is confirming that when left untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum disease can improve your blood sugar control reducing your risk for the serious complications. How is your diabetes control? GoodFairPoor Date of last A1c What score? Who is your diabetes Doctor? Some people are genetically prone to developing gum disease even if they decent care of their mouths. Do you have any family history of gum disease? YesNoI don't know Stress is a well- known risk factor for gum disease. Is your stress level too high? YesNo Life altering events (loss of jobs, divorce, death in family, moving to new location, etc.) can be particularly strong factors for gum disease. Are you currently going through any life altering events? YesNo There is a bi-directional connection between rheumatoid arthritis. If you have arthritis you are at an increased risk for gum disease. Emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of arthritis. Have you ever been diagnosed with Rheumatoid Arthritis? YesNo Yes Overweight Sleep Apnea/Snoring Being overweight is now recognized as a strong risk factor for gum disease. Obesity and gum disease are both risk factors for heart disease and diabetes. Thus, if you are over your ideal weight, it is vitally important for you to eliminate any gum inflammation to lower your risks for more serious health problems. We can calculate your weight status by using Body Mass Index (BMI) List your current weight List your current height BM I= (703 x weight)/ (height) ² 18.4 or below Underweight 18.5 to 24.9 Healthy Weight 25.0 to 29.9 Overweight ≥ 30.0 Obese Pauses in breathing or shallow breaths while sleeping is a common disorder often seen with snoring, overweight, or often tired individuals.. It is a potentially serious health threat to your heart and brain but one that can be relatively easy to diagnose and treat successfully. Has anyone told you that you snore? YesNo Have you noticed an increase in your breathing or heart rate when you wake from a nap or during your normal sleeping hours? YesNo Do you doze off while watching TV or reading quietly? Yes
