For new and existing patients that need to update health information. Step 1 of 2 50% Name* First Last Date of Birth* MM slash DD slash YYYY Patient Sex* Male Female Preferred Pharmacy: Primary Care Physician/# : Patient Health Questionaire Conditions. Check all that apply* Do you currently have or have you ever had any of the following? Asthma Bleeding Problems Epilepsy /Seizures Prosthetic Heart Valve Artifical Joint Hepatitis /Liver Disease Tuberculosis Cancer Chemo/Radiation AIDS/HIV Thyroid Disease Shortness of Breath Breathing Problems/COPD Steroid Use Kidney Problems Psychiatric Therapy Vertigo Hypertension Hypotension Chest Pain Congestive Heart Failure Anemia Sexually Transmitted Disease Eating Disorders Hospital/Surgery Any Addictions None of the Above Since you checked Asthma, where do you keep your inhaler?* Since you checked Artifical Joint, list/date* Since you checked Cancer, list type/date:* Since you checked Chemo/Radiation, list date:* Since you checked Hospital/Surgery, what and when?* Since you checked Addictions, please list* Other condition or disease not listed? Other Medical History Do you take blood thinners?* Yes, Coumadin Yes, Plavix No Please list names of medications , vitamins, and supplements you are taking.* Name of medication and condition for use. Write none if not applicable. Allergies. Check all that apply* Are you allergic to or have you ever had an adverse reaction to: Local Anesthetics/Novocain Latex Antibiotic Codeine Aspirin/Advil Any metals (ex. Nickel, Mercury ect.) Sulfa Drugs Barbiturates, Sedatives or Sleeping Pills None of the Above Since you checked Antibiotics, list* Any Other Allergies? Temporomandibular Joint Symptoms. Check all that apply* Do you have any jaw pain or headaches? The jaw/headache pain is frequent and/or severe Does it hurt to open wide/yawn, chew? Do you take muscle relaxers or pain relievers? None of the Above Level of Anxiety/Stress/Fear when going to the dentist? NoneMildModerateSevere Risk Factors. Check all that apply.* The following risk factors make it much easier for Periodontal (gum ) Disease to develop Current tobacco user Previous tobacco user Family history of gum disease? (Parents lost teeth at an early age, or gum disease on your side of the family) Stress Previous bouts of gum disease/gingivitis Spouse with gum disease (Gum disease may be transmissible, all family members should be screened) Osteoporosis Taking Dilantin, CA+ Channel Blockers, or Immunosuppressant’s for organ transplantation Diabetes None of the above Current Tobacco User, Additional Information Required* What kind? How much per day? How Long? Previous Tobacco User, Additional Information* What kind? How much per day? How Long? Heart Disease. Check all that apply.* Untreated gum disease can increase your risk for heart attack and stroke. Diagnosed with heart disease/stroke/heart attack Family history of heart disease High cholesterol High blood pressure None of the above Who is your Cardiologist? Diabetes. Check all that apply.* Diabetics are more prone to gum disease. Left untreated, gum disease makes it harder for diabetics to control their blood sugar. Diabetics who have their gum disease treated can improve their blood sugar control thus making diabetic complications less likely. You are a Diabetic There is a family history of Diabetes Frequent urination (warning sign of diabetes) Excessive thirst/hunger (warning sign of diabetes) Weakness/fatigue (warning sign of diabetes) Slow healing of cuts (warning sign of diabetes) Unexpected weight loss (warning sign of diabetes) None of the above How is your Diabetes control?* Good Fair Poor Date of last HbA1c and Score? Who is your Diabetes doctor ? Have you ever been diagnosed with Rheumatoid Arthritis?* If you have Rheumatoid Arthritis, emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of Arthritis. Yes No Alzheimer’s Disease* If you have Rheumatoid Arthritis, emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of Arthritis. Do you currently have Alzheimer’s Disease or Dementia Any family history of Alzheimer’s Disease or Dementia None of the above Females. Check all that Apply* Pregnant Nursing Taking Birth Control Pills Are you post Menopausal? Do you have Osteoporosis? Family history of Osteoporosis (Risk factor) Early menopause (Risk factor) Rheumatoid Arthritis (Risk factor) Inadequate exercise (Risk factor) None of the above Have You Ever Taken the Following Medications?* Fosamax, Fosamax Plus D, Actonel, Boniva, Didronel, Skelid, Aredia, Bonefors, or Zometa for Osteoporosis or for any other reason? Yes No
