DENTAL INTAKE QUESTIONNAIRE

Directions To Patients: Answers to these questions will help the dentist decide how to best treat your dental problem. Please try to answer each question to the best of your knowledge. Medical and Social History 1. List all the medications or drugs you are presently taking.Medications Reasons

2. Do you have or have you had any of the followingdiseases or complications? (If yes,./)o Heart Infections o High or low blood pressureo Heart Murmur o Strokeo Rheumatic Fevero Endocarditiso Heart Attack/Coronaryo Heart Surgeryo Anginao Hemophiliao Asthma

o Hepatitiso HIV+

o Diabeteso Tuberculosiso Epilepsy (Seizures)o Knee or hip joint replacemento Glaucoma

Yes I No 3. Have you been treated by a physician or been in the hospitalin the past year? ......................................... ."........ .. . . . . . . . . . . . . o ..... o4. Are you now pregnant or think you are pregnant?..... o ..... o

Date expecting:------------5. Are you now taking birth control pills?... .................... o ..... o6. Have you been treated for some allergic condition?... o ..... o7. Are you allergic to penicillin? .......................................... o ..... o 8. Has anyone ever told you not to take a particular drug(aspirin, novacaine, sulfa, etc.)?....................................... o ..... o9. Are there any medications that make you sick or ill?... o ..... o10. Do you take medication for nerve or emotional. problems?................................................................................................ .0 ..... 0 1 I. Have you ever had prolonged bleeding (more than is normal for you) from a cut, injury, or tooth extraction?. o ..... o12. Have you ever had anemia, low blood or thin blood?... o ..... o13. Have you ever had other serious or disabling problemswith your blood, spleen or lymph nodes?......................... o ..... o14. Do you smoke or drink? How Often?: o ..... o15. Have you ever had blackout or fainting spells (suddenlylost track of things for a few minutes)?............................ o ..... o16. Have you taken daily cortisone medication{Prednisone) inthe past year? ................................................................... o ..... oI 7. Have you ever had stomach or duodenal ulcers?........ o ..... o18. Have you ever had pain in your jaw joint..................... o ..... oI 9. Do you have any serious or disabling problems with your bones,joints or muscles?................................................. o ..... o20. Have you had surgery or x-ray treatment for a tumor,growth or other condition of your mouth or lips?...... o ..... o21. Any other medical problems? ........................................ o ..... o

PATIENT LABEL AREA

lnstrucciones A Los Pacientes: Respondiendo a estas preguntas ayudara en la decision para el mejor tratamiento a su problema dental. Trate de contestar cada pregunta. Historia Medica Y Social 1. Anote las medicinas 6 drogas que esta tomando.Medicinas Razon

2. ('.Padece o ha padecido de alguna de las siguientesenfermedades? (Si si, ./) o Presi6n arterial alta 6 bajao Infecciones de! corazon o Derrame cerebralo Soplo en el coraz6n o Hepatitiso Fiebre Reumatica o HIV + I VIHo Endocarditis o Diabetiso Ataque al coraz6n/coronariao Operaciones de! coraz6no Angina pectoralo HemofiliaOAsma

o Tuberculosiso_Epilepsia 6 convulsioneso Radilla o articulaci6n de· cadera reemplazoo Glaucoma

3. ('.Ha sido tratado por un medico 6 ha estado en elhospital el afi.o pasado? ............................................... CJ .•.•• o

4. ('.Esta o piensa que puede estar embarazada? ............... CJ •••• o Fecha de espera: _____________ �

5. ('.Esta tomando pastillas para el control de la natalidadU .... o 6. ('.Ha sido tratado por condiciones alergicas? ................. .o ... o 7. ('.Es alergico a Ia penicilina? ......................................... JJ •.•. o 8. ('.Lehan dicho alguna vez que no tome alguna

medicina? (aspirina, novocaina, sulfa, etc.) .................. CJ .•. o 9. ('.Ha tornado alguna medicina que lo haga sentir ma!? .. CJ ••• o10. lEsta tomando medicinas para los nervios o problemas

emocionales? .............................................................. JJ •••. CJ 11. lHa sangrado mas de Io normal por una herida oextracci6n dental?.............................................................. ................. 0 .... 0 12. lHa padecido de anemia? ......................................... .C:l ••.. o 13. lHa padecido algun problema serio de la sangre, bazo

o glandulas Iinfacticas? ............................................. 0 .... 0 14. lFuma o bebe? ('.Cuanto?: ..................... 0 .... 015: lHa padecido de desmayos ( de pronto ha perdido la nocion

de las cosas por unos minutes)? .................................. J:l ... o 16. lHa tornado medicina de cortisona diariamente? ....... JJ ... o 17. lHa padecido de ulceras de! estomago o duodenale? .. o .... o 18. lHa padecido de dolores en las coyuntras de Ia quijado o

mandibula? ................................................................ JJ .... o 19. lTiene algun problema serio o incapacitante con sus

huesos, coyunturas o musculos? ................................. 0 ... o 20. lHa tenido alguna operacion o tratamiento de rayos-x• · por un·tumor u otra condicion de la boca o labios? ..... CJ ••• o 21.lPadece usted de algun significante problema medico'tl .... o

_______________________

_______________________

_______________________

_______________________

DENTAL HISTORY HISTORIA DENTAL

Pae 2

YesjNo Sil No 1. Why do you want to see a dentist? 1. 6Por que quiere ver un dentista?

--------

2. Have you ever been to a dentist before? ...................... o ..... o 2. 6Ha estado anterionnente en el dentista? ....................... o ..... oIf yes, about when was the last time? 6Cuando? 6Por que razon? __________ _ For what reason? -3, lLe ban-tornado, una serie completa de rayos-x de los

3. Have you ever had a complete series ofx-rays taken of your dientes? .............................................................................. o ..... o teeth? .................................................................................. 0 ..... 0 lSi si, cuando fue la ultima?O 1 aflo O 2 aflos O 3 ai'ios o mas If yes, when was the last: 0 I year O 2 years O 3 yrs or more 4. lCuantas veces al dia se lava los dientes? ____ _

4. · How many times a day do you brush your teeth?_ 5. lLe ha ensei'iado algun (dentista, higienista, enfermera o5. Has anyone (dentist, hygienist, nurse or physician) ever medico) como limpiarse los dientes? ................................ o ..... o shown you how to clean your teeth?.............................. o ..... o 6. lUsa hilo dental regularmente? ....................................... o ..... o 6. Do you use dental floss regularly? ................................. D ..... o 7. lHa tenido alguna vez tratamiento para las encias? ..... o ..... o 7. Have you ever had treatment for your gums?............... o ..... o 8. lCuando se cepilla los dientes le duelen o sangran las 8. Do your gums bleed or hurt when you brush them?.,._.. o., .. ,q .. e.ncias? .,.,.0,;,.,, ••

1,, ....... , ........... ,., .......................................... o ..... o9. Do your teeth feel loose? ................................................ .0 ..... 0 9. lSe siente sus dientes flojos? .......................................... o ..... o 10. Are you sensitive to heat, cold, or sweets?................. o ..... o 10. lSon sus dientes sensitivos a lo caliente, lo frio, o lo dulce?11. Do any teeth hurt when you chew? ............................... o ..... o ............................................................................................... 0 ..... 0 12. Do you clamp, clench, or grind your teeth during the day or 11. 6Cuando mastica, le duele algun diente o muela? ....... o ..... o

night? ................................................................................ .0 ..... 0 12. lFija, aprieta, o masculla usted los dientes durante el dia o13. Have you been aware of any swelling in the face or neck? la noche? ............................................................................ o ..... o

.......................................................................................... Q ..... O 13. lSe la ha hinchado SU cara O cue!lo? ............................. 0 ..... 014. Do you have other serious or disabling tooth, gum, or jaw 14. 6Tiene algun otro problema serio con sus dientes, encias o

problems? .......................................................................... i::i ..... o mandibula? ...................................................................... o ..... o 15. For Parents: 15. Para los padres:

1

Does your child suck his thumb? ................................... 0 ..... 0 6Se chupa su hijo el dedo? ................................................ 0 ..... 0 Does your child go to sleep with the bottle in his/her 6Se duerme su hijo con la botella de leche en la boca?.. o ..... o mouth? ............................................................................ .Q ..... o

To the best of my knowledge, the foregoing medical and dental questions have been accurately answered.

(If a minor, parent or guardian must sign)

Dentist's Signature: ______________ _

He contestado lo mejor y lo mas correcto posible las preguntas anteriores.

(Si menor, padre o guardian)

Dentist's Signature: ---------------

EXAMINING DENTIST'S SUMMARY OF SIGNIFICANT MEDICAL FINDINGS: REVIEW OF HEALTH HISTORY AND

MEDICAL RECORD

(Update at each recall)

Date Signature

Medical Referral To:

Dental Precautions:

155 Bay Street Staten Island, NY 10301 Telephone: 718.876.8100 Fax: 718.876.8100

www.baydentalatthepointe.com