Patient Intake Form Patient Intake Form Patient Intake Form (#2)First NameLast NamePatient AgePatient Gender- Select -MaleFemaleOthersPhone no.Marital Status Married Unmarried otherMarital status(other)OccupationDisability ? Yes NoGeneral Medical HistoryAre you in good general health? Yes NoAre you PRESENTLY under a physician's care? Yes NoIf Yes, please include your Physicians InformationHas there been any change in your general health in the past year? Yes NoMy last physical examination was on:Have you had any serious illness or operation? Yes NoIf Yes, please list:Cardiovascular SystemDo you have or have ever had any of the following: Please check Heart trouble Heart attack Coronary insufficiency Mitral valve prolapse Stroke Damaged heart valves Congenital heart diseaseRheumatic heart disease, heart murmur? Yes NoChest pain after exertion? Yes NoShortness of breath after mild exercise Yes NoDo you have ankles swell? Yes NoDo you use extra pillow to sleep? Yes NoDo you have a cardiac pacemaker? Yes NoDo you have any blood pressure problem? if YES: High LowCentral Nervous SystemDo you have or have you ever had: Epilepsy Fainting Spells Seizures Emotional disturbancesDo you follow any treatment for a nervous disease? Yes NoRespiratory SystemDo you have a persistene cough or cold? Yes NoDo you have or have you ever had tuberculosis? Yes NoDo you have any sinusitis, sinus trouble? Yes NoDo you have emphysema, chronic bronchitis, asthma? Yes NoDigestive SystemDo you have any stomach ulcers? Yes NoDo you have or have you ever had? Acid Reflux (GERD) Hepatitis Jaundice Liver DiseaseHave you ever vomitted blood? Yes NoDo you have ANY diarrhea? Yes NoEndocrine SystemDo you have diabetes? Yes (Controlled) Yes (Uncontrolled) NoDoes anyone in your family have diabetes? Yes NoDo you urinate more than six times a day? Yes NoAre you thirsty very often or have dry mounth? Yes NoDo you have hypothyroidism or hyperthyroidism? Yes NoHematogenic SystemDo you have anemia, Sickle cell disease or any other blood disorder? Yes NoIs there ANY family history of blood disorders? Yes NoAre you hemophilic? Yes NoHave you ever had abnormal bleeding after any surgery, extration or trauma? Yes NoHave you ever had a blood transfusion? Yes NoImmunodeficiency problem? Yes NoAllergiesAre you allergic or have you reacted adversely to: Local anesthetic Penicillin Barbiurates, sedatives, or sleeping pills Iodine Latex Hay fever Hives or skin rash Antibiotics Sulfa Drugs Aspirin Codeine or other narcotics Asthma Seasonal allergiesGenitourinary SystemDo you have or have you ever had? Kidney trouble Dialysis Syphillis, gonorrheaBones & JointsDo you have or have ever had? Arthritis Inflammatory rheumatism Bone infection Bone infection Osteporosis Artificial Join Replacement Receive or currently receiving the intravenous medication known as Zomata (IV) or Aridia (IM) Currently taking or have taken the oral medication bisphosphate for osteoporosis or Fosamax, Acetonal or BonivaHave you noticed any changes in your mounth or jaws? Yes NoHave you notices any foul smell, swelling or discharge in your mounth? Yes NoOtherDo you have or have you ever had? Tumor or malignancy Chemiotherapy or radiation therapyDo you have or have you ever had ANY Disease or condition or problem NOT listed above that you think we should know about? If so, please explain:Are you regularly exposed to x-rays or ANY other ionizing radiation or toxic substances? Yes NoDo you have glaucoma? if so: Yes (Wide) Yes (Close) noAre you wearing or do you wear contact lenses? Yes NoDo you do any of the following: Smoke tobacco Drink alcohol Use oral tobaccoFor womenAre you currently: Pregnant Undergoing hormonal therapy Taking oral contraceptives NursingDo you have any problems associated with your menstrual cycle? Yes NoYour MedicationMedication List, please wirte what kind of medication you are taking as well as the dosage (Prescription or over the Counter)Dental historyWhat is your cheif dental complaint?Are you experiencing any discomfort or pain at this time? Yes NoAre you satisfied with the appearance of your teeth? Yes NoAre you able to eat or chew foods satisfactorily? Yes NoDo you have headaches, earaches, or neck pain? Yes NoDo you frequently experience sinus problems? Yes NoHave you ever had ANY serious trouble associated with ANY previous dental tratment? If yes, please explain: Allergies Artificial Joints Bisphosphate Fosimax Carpal Tunnel Syn Dizziness Fainting Hay Fever Heart Murmur HIV Jaundice Liver Disease Nervours Disorders Pacemaker Pre Medicate Respitory Problems Sinus Problems Sulfa Allergy Tubercolosis Venereal DiseaseCheckbox Field Anemia Aspirin Allergy Blood Disease Codeine Allergy Epilepsy Glaucoma Head Injuries Hepatitis Hyperthyroidism Kidney Disease Mental Disorder Osteoporosis Penicillin Allergy Pregnany Rheumatic Fever Stomach Problems Swollen Glands, Neck Tumors Zythromax AllergyCheckbox Field Arthritis Asthma Cancer Diabetes Excessive Bleeding Growths Heart Disease High Blood Pressure Hypothyroidism Latex Allergy MVP Other Percocet Allergy Radiation Treatment Theumatism Stroke Topical Anesthetic UlcersUpload medical recordsUpload your blood exam no older than 6 monthsChoose File Upload your last x-ray no older than 1 yearChoose File Take a photo of your teeth with your cell. Upper maxilla and lower. You need to introduce the movil for both archs. then you take one with open mouth. The last one is with close mouth. Choose File I have read and agree to the Terms and Conditions and Privacy PolicySubmit
