Perfect Smiles
Your Dentist in the San Diego and Mission Valley Community
Patient Information Form(please complete before your visit)
GENERAL INFORMATION
  1. PERSONAL INFO:
  2. HOME ADDRESS:

  3. BILLING ADDRESS (If Different):
  4. CONTACT INFORMATION:
  5. PERSON TO CONTACT IN CASE OF EMERGENCY:
  6. INSURANCE INFORMATION:
  7. HEALTH CARE PROVIDER INFORMATION:
DENTAL HEALTH HISTORY
    1. Are you apprehensive about dental treatment?
    1. Have you had problems with previous dental treatment?
    1. Do you gag easily?
    1. Do you wear dentures?
    1. Does food catch between your teeth?
    1. Do you have difficulty in chewing your food?
    1. Do you chew on only one side of your mouth?
    1. Do you avoid brushing any part of your mouth because of pain?
    1. Do your gums bleed easily?
    1. Do your gums bleed when you floss?
    1. Do your gums feel swollen or tender?
    1. Have you ever noticed slow-healing sores in or about your mouth?
    1. Are your teeth sensitive?
    1. Do you feel twinges of pain when your teeth come in contact with:Hot foods or liquids?
    1.   Cold foods or liquids?
    1.   Sours?
    1.   Sweets?
    1. Do you take fluoride supplements?
    1. Are you dissatisfied with the appearance of your teeth?
    1. Do you prefer to save your teeth?
    1. Do you want complete dental care?
    1.   How often do you brush?
    1.   How often do you floss?
    1. Does your jaw make noise so that it bothers you or others?
    1. Do you clench or grind your jaws frequently?
    1. Do your jaws ever feel tired?
    1. Does your jaw get stuck so that you can't open or close freely?
    1. Does it hurt when you chew or open wide to take a bite?
    1. Do you have earaches or pain in front of the ears?
    1. Do you have any jaw symptoms or headaches upon awaking in the morning?
    1. Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
    1. Do you find jaw pain or discomfort extremely frustrating or depressing?
    1. Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
    1. Do you have a temporomandibular (jaw) disorder(TMD)?
    1. Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
    1. Are you unable to open your mouth as far as you want?
    1. Are you aware of an uncomfortable bite?
    1. Have you had a blow to the jaw (trauma)?
    1. Are you a habitual gum chewer or pipe smoker?
    1. Do you snore?
    1. Are you excessively tired during the day?
    1. Have you been told you stop breathing during sleep?
    1. Is your neck size greater than 17 inches(male) or 16 inches (female)
MEDICAL HEALTH HISTORY
    1. Heart Problems
    1.   Chest pain
    1.   Shortness of breath
    1.   Blood pressure problem
    1.   Heart murmur
    1.   Heart valve problem
    1.   Taking heart medication
    1.   Rheumatic fever
    1.   Pacemaker
    1.   Artificial heart valve
    1. Blood Problems
    1.   Easy bruising
    1.   Frequent nosebleeds
    1.   Abnormal bleeding
    1.   Blood disease (anemia)
    1.   Ever require a blood transfusion?
    1. Allergy Problems
    1.   Hay fever
    1.   Sinus problems
    1.   Skin rashes
    1.   Taking allergy medication
    1.   Asthma
    1. Intestinal Problems
    1.   Ulcers
    1.   Weight gain or loss
    1.   Special diet
    1.   Constipation/Diarrhea
    1.   Kidney or bladder problems
    1. Bone or Joint Problems
    1.   Arthritis
    1.   Back or neck pain
    1.   Joint replacement(e.g., total hip, pins, or implants)
    1.   Are you taking or have you taken Bisphosphonate(e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast , etc.)
    1. Fainting Spells, Seizures, or Epilepsy
    1. Stroke(s)
    1. Frequent or severe headaches
    1. Thyroid problems
    1. Persistent cough or swollen glands
    1. Premedications required by physician
    1. Cancer/Tumor
    1. Diabetes
    1.   Urinate more than 6 times a day
    1.   Thirsty or mouth is dry much of the time
    1.   Family history of diabetes
    1. Tuberculosis or other respiratory disease
    1. Do you drink alcohol?
    1.   If so, how much?
    1. Do you smoke?
    1.   If so, how much?
    1. Hepatitis, jaundice, or liver trouble
    1. Herpes or other STD
    1. HIV-positive/AIDS
    1. Glaucoma
    1. Do you wear contact lenses?
    1. History of head injury?
    1. Epilepsy or other neurological disease?
    1. History of alcohol or drug abuse?
    1. Do you have any disease, condition, or problem not listed previously that you feel we should know about?
    1.   If so, please describe);
  1.  
  2. ARE YOU ALLERGIC, OR HAVE YOU REACTED ADVERSELY,TO ANY OF THE FOLLOWING?
    1. Aspirin
    1. Codeine
    1. Dental Anesthetics
    1. Erythromycin
    1. Jewelry
    1. Latex
    1. Metals
    1. Penicillin
    1. Tetracycline
    1. Sulfa
    1.   Other
  3.  
  4. DURING THE PAST 12 MONTHS, HAVE YOU TAKEN ANY OF THE FOLLOWING?
    1. Antibiotics or sulfa drugs
    1. Anticoagulants (e.g., Coumadin)
    1. High blood pressure medicine
    1. Tranquilizers
    1. Insulin, Orinase, or similar drug
    1. Aspirin
    1. Digitalis or drugs for heart trouble
    1. Nitroglycerin
    1. Cortisone (steroids)
    1. Natural remedies
    1. Nonprescription drug/supplements
    1.   Other
  5.  
  6. WOMEN
    1. Are you taking contraceptives or other hormones?
    1. Are you pregnant?
    1.   If so, expected delivery date:
    1. Are you nursing?
    1. Have you reached menopause?
    1.   If so, do you have any symptoms?
  7.  
  8. List Medications You Are Taking:
  9.  
  10. DATE: 2017-11-19