Patient Health History - Adult | Giordano Family Dentistry

PATIENT INFORMATION

Date of Completion*

*

Name:*

First Last

Age:*

Date of Birth:*

Referred By:*

*

Location and/or Phone Number of Healthcare Provider:*

Patient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Alternate Contact Number

Type of Employment*

Please Identify Yourself*

I am the Patient
I am the Responsible Party

Responsible Party (if different than Patient)*

Address of Responsible Party (if different than Patient)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Dentist:*

Address and/or Phone Number*

Family Physician:*

Address and/or Phone Number*

Reason(s) for this appointment:*

Pain
Sleep/Airway
Orthodontics
Unknown

WHAT IS THE CHIEF COMPLAINT FOR WHICH YOU ARE SEEKING TREATMENT IN OUR OFFICE?

NOTE: PLEASE IDENTIFY YOUR CHIEF COMPLAINT IN PARAGRAPH BELOW. LIST ALL OTHER SYMPTOMS IN PRIORITY #2-9.

Symptom:*

For each symptom checked above, please list whether it is recent or chronic (6 mo.+ )*

Do you have concerns in any of these areas:*

General Appearance
Ability to Function
Overbite
Smile
I Do Not Have Any Concerns Listed Above

Other Comments:

Do any of the above complaints affect your daily life?*

WHAT ARE THE RESULTS YOU ARE SEEKING FROM TREATMENT?*

ALLERGIC REACTIONS

PLEASE CHECK ANY AND ALL MEDICATIONS OR SUBSTANCES THAT HAVE CAUSED AN ALLERGIC REACTION

*

If Other, please explain:

CURRENT MEDICATIONS

Are you currently taking any medications?*

Yes
No

PLEASE LIST ALL MEDICATIONS YOU ARE TAKING AND THE REASON YOU ARE TAKING THEM. INCLUDE ALL OVER-THE-COUNTER MEDICATIONS, VITAMINS, HERBS, ETC.

Medication*

Dosage*

Reason for Taking*

PREVIOUS TREATMENTS/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

Was This Current Condition Previously Treated?*

Yes
No

Treatment and/or Medication*

Doctor/Provider Name*

Approximate Date of Treatment*

I RELEASE AND GIVE MY PERMISSION FOR THIS OFFICE TO REQUEST INFORMATION AND COMMUNICATE WITH THE PROVIDERS LISTED ABOVE.

HEALTH AND MEDICAL HISTORY

Are you currently pregnant?*

Yes
No

Have you sustained an injury to:*

Head
Neck
Face
Teeth
Other
None

Do you drink 4 or more cups of coffee per day?*

Yes
No

Have you had prior orthodontic treatments?*

Yes
No

Trouble breathing through nose?*

Yes
No

Do you smoke tobacco?*

Yes
No

Do you consume alcohol or take sedatives?*

Yes
No

HEALTH AND MEDICAL HISTORY (CONTINUED)

PLEASE CHECK IF YOU HAVE, OR HAVE EXPERIENCED ANY OF THE FOLLOWING:

Check if yes:*

Any additional information:

SURGICAL HISTORY

PLEASE CHECK IF YOU HAVE YOU HAD ANY OF THE FOLLOWING SURGERIES:

*

General Anesthesia
Adnoids removed
Tonsils removed
Jaw Joint Surgery
Orthognathic Surgery
Oral Surgery
Revmoval of third molar (wisdom teeth)
Other Surgery
I Have Not Had Any of the Listed Surgeries

List Other types of surgery:*

CURRENT SYMPTOMS

Head Pain

L = Left, R = Right, B = Bilateral

Have You Experienced Any Head Pain?*

Yes, I Have Had Head Pain
No, I Have Not Had Head Pain

Frontal (Forehead)

L
R
B

Check all that apply:*

Generalized

L
R
B

Check all that apply:*

Parietal (Top of head)

L
R
B

Check all that apply:*

Occipital (Back of head)

L
R
B

Check all that apply:*

Temporal (Temple area)

L
R
B

Check all that apply:*

Jaw Pain

L = Left / R = Right

Have You Experienced Any Jaw Pain?*

Yes, I Have Had Jaw Pain
No, I Have Not Had Jaw Pain

Jaw Pain with opening

L
R

Jaw Pain when chewing

L
R

Jaw Pain at rest

L
R

Jaw Sounds

L = Left / R = Right

Have You Experienced Any Jaw Sounds?*

Yes, I Have Had Jaw Sounds
No, I Have Not Had Jaw Sounds

Jaw Sounds with opening

L
R

Jaw Sounds when chewing

L
R

Jaw Sounds at rest

L
R

Jaw Locking

L = Left / R = Right

Have You Experienced Any Jaw Locking?*

Yes, I Have Had Jaw Locking
No, I Have Not Had Jaw Locking

Jaw locks closed

Yes
No

Jaw Locks Open

Yes
No

Jaw Joint Symptoms

L = Left / R = Right

Have You Experienced Any Jaw Joint Symptoms?*

Yes, I Have Had Jaw Joint Symptoms
No, I Have Not Had Jaw Joint Symptoms

Teeth Clenching

Yes
No
Day
Night

Teeth Grinding

Yes
No
Day
Night

Eye Related Conditions

Have You Experienced Any Eye Related Conditions?*

Yes, I Have Had Eye Related Conditions
No, I Have Not Had Eye Related Conditions

Blurred Vision

Yes
No

Double Vision

Yes
No

Eye Pain

Yes
No

Pain or pressure behind the eyes

Yes
No

Extreme sensitivity to light (photophobia)

Yes
No

Wear of glasses or contact lenses

Yes
No

Ear Related Conditions

L = Left / R = Right

Have You Experienced Any Ear Related Conditions?*

Yes, I Have Had Ear Related Conditions
No, I Have Not Had Ear Related Conditions

Buzzing in the ears

L
R

Ear congestion

L
R

Ear pain

L
R

Hearing loss

L
R

Itchiness or Stuffiness in ears

L
R

Pain behind the ear

L
R

Pain in front of the ear

L
R

Recurrent ear infections

L
R

Ringing in the ear (Tinnitus)

L
R

Throat Related Conditions

Have You Experienced Any Throat Related Conditions?*

Yes, I Have Had Throat Related Conditions
No, I Have Not Had Throat Related Conditions

Chronic sore throat

Yes
No

Difficulty swallowing

Yes
No

Swollen glands

Yes
No

Thyroid enlargement

Yes
No

Tightness in throat

Yes
No

Constant feeling of foreign object in throat

Yes
No

Neck Related Conditions

Have You Experienced Any Neck Related Conditions?*

Yes, I Have Had Neck Related Conditions
No, I Have Not Had Neck Related Conditions

Limited movement of neck

Yes
No

Neck pain

Yes
No

Numbness in hands or fingers

Yes
No

Swelling in the neck

Yes
No

Shoulder Related Conditions

Have You Experienced Any Shoulder Related Conditions?*

Yes, I Have Had Shoulder Related Conditions
No, I Have Not Had Shoulder Related Conditions

Shoulder pain

Yes
No

Shoulder stiffness

Yes
No

Tingling in hands or fingers

Yes
No

Back Related Conditions

Have You Experienced Any Back Related Conditions?*

Yes, I Have Had Back Related Conditions
No, I Have Not Had Back Related Conditions

Back pain - lower

Yes
No

Back pain - middle

Yes
No

Back pain - upper

Yes
No

Sciatica

Yes
No

Scoliosis

Yes
No

Mouth and Nose Related Conditions

Have You Experienced Any Mouth & Nose Related Conditions?*

Yes, I Have Had Mouth & Nose Related Conditions
No, I Have Not Had Mouth & Nose Related Conditions

Dry mouth

Yes
No

Chronic sinusitis

Yes
No

Frequent snoring

Yes
No

Burning tongue

Yes
No

Broken teeth

Yes
No

Frequent biting of the cheek

Yes
No

Sleep Conditions

Have You Experienced Any Sleep Related Conditions?*

Yes, I Have Had Sleep Related Conditions
No, I Have Not Had Sleep Related Conditions

Sleep Positions

Side
Back
Stomach
Varies

Is it easy to fall asleep?

Yes
No

Do you feel rested upon waking?

Yes
No

Stopped breathing during sleep?

Yes
No

Average hours of sleep per night?

Do you wake often during the night?

Yes
No

Gasping or choking during sleep?

Yes
No

Have you ever had a Sleep Study (PSG)?

Yes
No

If yes, the result was:

HISTORY OF SYMPTOMS:

On what date, or approximate date, did this condition or symptoms first occur?*

Does any family member have the same or similar problem? If yes, please explain:*

Can you relate your pain or condition to a motor vehicle accident or traumatic injury? If yes, please complete Trauma History Section, enclosed as a separate form.*

I authorize the release of all examinations, findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage.

Electronic Signature (E-Signature) Agreement

By selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*

I Accept

Electronic Signature:

Name*

First Last

Today's Date*

Phone

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