Bluegrass Dentistry, offering the latest in dental techniques

Today's Date *

Month

Day

Year

General Information

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.

First Name *

Middle Name *

Last Name *

Email: *

Home Phone *

Business/Cell Phone

Street Address *

City *

State *

Zip Code *

Occupation

Height *

Weight *

Birthday *

Month

Day

Year

Sex *

Are you currently pregnant? *

Yes

Number of weeks

Taking birth control pills or hormonal replacement?

Yes

Nursing?

Yes

SSN or Patient ID - This is required in order to process insurance *

Emergency Contact *

Relationship *

Emergency Contact Home Phone *

Emergency Contact Cell Phone *

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Will we be helping you file your dental insurance claims? *

Yes

Insurance Company *

Phone number / Provider number on back of card *

Subscriber / Primary Insurance Holder Name (First and last) *

Subscriber's Date of Birth *

Month

Day

Year

Subscribers SSN *

Dental Information

For the following questions, please check your responses to the following questions. (Check DK if you Don't Know the answer to the question)

Do your gums bleed when you brush or floss? *

Yes

Are you currently experiencing dental pain or discomfort? *

Yes

Are your teeth sensitive to cold, hot, sweets or pressure? *

Yes

Do you brux or grind your teeth? *

Yes

Do you drink bottled or filtered water? *

Yes

Do you have any clicking, popping or discomfort in the jaw? *

Yes

Do you have earaches or neck pains? *

Yes

Do you have sores or ulcers in your mouth? *

Yes

Do you participate in active recreational activities? *

Yes

Do you wear dentures or partials? *

Yes

Does food or floss catch between your teeth? *

Yes

Have you ever had a serious injury to your head or mouth? *

Yes

Have you ever had orthodontic (braces) treatment? *

Yes

Have you had any periodontal (gum) treatments? *

Yes

Have you had any problems associated with previous dental treatment? *

Yes

Is your home water supply fluoridated? *

Yes

Is your mouth dry? *

Yes

Date of your last dental exam?

Month

Day

Year

What was done at that time?

Date of last dental x-rays?

Month

Day

Year

What is the reason for your dental visit today? *

How do you feel about your smile?

Medical Information

For the following questions, please check your responses to the following questions. (Check DK if you Don't Know the answer to the question)

Are you now under the care of a physician? *

Yes

Physician Name *

Physician Address *

Physician City *

Physician State *

Physician Zip Code *

Are you in good health?

Yes

Has there been any change in your general health within the past year?

Yes

If yes, what condition is being treated?

Date of last physical exam?

Month

Day

Year

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)? *

Yes

Please list all, including vitamins, natural or herbal preparations and/or diet supplements?

Do you wear contact lenses? *

Yes

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes

Date of joint replacement

Month

Day

Year

Have you had any complications?

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®)for osteoporosis or Paget’s disease? *

Yes

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? *

Yes

Date of treatment

Month

Day

Year

Do you use controlled substances (drugs)? *

Yes

Do you use tobacco (smoking, snuff, chew, bidis)? *

Yes

How interested are you in stopping? *

Very

Somewhat

Not Interested

Do you drink alcoholic beverage? *

Yes

If yes, how much alcohol did you drink in the last 24 hours? *

How much do you typically drink In a week? *

Allergies

Local anesthetics *

Yes

Aspirin *

Yes

Penicillin or other antibiotics *

Yes

Barbiturates, sedatives, or sleeping pills *

Yes

Sulfa drugs *

Yes

Codeine or other narcotics *

Yes

Metals *

Yes

Latex (rubber) *

Yes

Iodine *

Yes

Hay fever/seasonal *

Yes

Animals *

Yes

Food *

Yes

Other

Please mark your response to indicate if you have or have not had any of the following diseases or problems.

Artificial (prosthetic) heart valve *

Yes

Damaged valves in transplanted heart *

Yes

Previous infective endocarditis *

Yes

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD *

Yes

Repaired (completely) in last 6 months *

Yes

Repaired CHD with residual defects *

Yes

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease *

Yes

Angina *

Yes

Arteriosclerosis *

Yes

Congestive heart failure *

Yes

Damaged heart valves *

Yes

Heart attack *

Yes

Heart murmur *

Yes

Low blood pressure *

Yes

High blood pressure *

Yes

Abnormal bleeding *

Yes

Anemia *

Yes

Mitral valve prolapse *

Yes

Other congenital heart defects *

Yes

Pacemaker *

Yes

Rheumatic fever *

Yes

Rheumatic heart disease *

Yes

Blood transfusion *

Yes

Transfusion Date *

Month

Day

Year

Hemophilia *

Yes

AIDS or HIV infection *

Yes

Arthritis *

Yes

Autoimmune disease *

Yes

Rheumatoid arthritis *

Yes

Systemic lupus erythematosus *

Yes

Asthma *

Yes

Bronchitis *

Yes

Emphysema *

Yes

Sinus trouble *

Yes

Tuberculosis *

Yes

Cancer/Chemotherapy/Radiation Treatment *

Yes

Chest pain upon exertion *

Yes

Chronic pain *

Yes

Diabetes Type I or II *

Yes

Eating disorder *

Yes

Malnutrition *

Yes

G.E. Reflux/persistent heartburn *

Yes

Gastrointestinal disease *

Yes

Ulcers *

Yes

Epilepsy *

Yes

Fainting spells or seizures *

Yes

Glaucoma *

Yes

Hepatitis, jaundice or liver disease *

Yes

Stroke *

Yes

Thyroid problems *

Yes

Neurological disorders *

Yes

Please Explain *

Sleep disorder *

Yes

Mental health disorders *

Yes

Please Explain *

Recurrent Infections *

Yes

Type of infection *

Excessive urination *

Yes

Kidney problems *

Yes

Night sweats *

Yes

Osteoporosis *

Yes

Persistent swollen glands in neck *

Yes

Severe headaches/migraines *

Yes

Severe or rapid weight loss *

Yes

Sexually transmitted disease *

Yes

Active Tuberculosis

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question). Note: If you answer yes to 4 of the listed questions. Please do not continue this form and call Bluegrass Dentistry directly to setup an appointment.

Active Tuberculosis *

Yes

Been exposed to anyone with tuberculosis *

Yes

Cough that produces blood *

Yes

Persistent cough greater than a 3 week duration *

Yes

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? *

Yes

Name of physician or dentist making recommendation. *

Phone *

Do you have any disease, condition, or problem not listed above that you think I should know about? *

Yes

Please explain *

Approval *

Yes

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.

New Patient Information