ProSites, Inc.



CONFIDENTIAL DENTAL/MEDICAL QUESTIONNAIRE FOR THE DENTAL OFFICE OF DR. MARY ANN HANLONDate______________________Name____________________________________________________________________________________Address_____________________________________City_____________State________Zip Code________Home Ph_________________________Cell Ph____________________Work Ph______________________ E mail address____________________________________________________________________________Preferred method of contact_________________________________________________________________Birth Date___/___/_______ Sex M F SSN______-________-___________Marital Status S M D W Other Occupation______________________________________________Height___________Weight___________Blood Pressure___________________Emergency contact________________________________________________________________________If you are completing this form for the patient, what is your relationship to the patient? _________________________________________________________________________________________Primary Dental Insurance Information: Company Name___________________________________________________________________________Company Address_________________________City____________State________Zip Code_____________Employee______________________________________Employer___________________________________Employee SSN______-______-___________ Employee Birth Date______/______/________Secondary Dental Insurance Information: Company Name___________________________________________________________________________Company Address__________________________City_____________State________Zip Code__________Employee_____________________________________Employer___________________________________Employee SSN______-_____-_____________Employee Birth Date______/______/___________ DENTAL INFORMATIONDentist_________________________________________________________________________________Referred by_____________________________________________________________________________Reason for referral_______________________________________________________________________Date of most recent dental examination_____/______/______How often do you get your teeth professionally cleaned_________________________________________Please describe your personal oral hygiene routine______________________________________________ Please describe any concerns you have with your mouth _________________________________________ __________________________________________________________________________________________Does the idea of periodontal treatment make you anxious? Y N If yes, please explain:_____________________________________________________________________________ Do you have bleeding gums, bad taste in your mouth or mouth odor? Yes No Have you had periodontal treatment in the past? Yes NoDoes food wedge in between your teeth? Yes NoIs your mouth frequently dry? Yes NoDo you have a mouth breathing or snoring habit? Yes NoDo you clench or grind your teeth? Yes NoDENTAL INFORMATION CONTINUEDHave you ever had orthodontic treatment? If yes, when? ______________________________ Yes NoHave you ever had any serious problem with previous dental treatment? Yes NoIf yes, please explain____________________________________________________ MEDICAL INFORMATION Which describes your general health: Excellent Good Fair PoorMy last physical examination was on__________________________________________________________Please provide the names and contact information of your physician(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please explain any serious illnesses, hospitalizations and/or surgeries you have had: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list all herbal supplements, nutritional supplements, prescription- and over the counter medications you are taking and the doses: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please circle any/all of the following to which you have had a reaction: local anesthetics Penicillin or other antibiotics sulfa drugs aspirin iodine latex codeine or other narcotics barbiturates/sedatives/sleeping pills any metals otherPlease explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever been treated with any of the following bisphosphonate drugs (Actonel, Aredia, Boniva, Fosamax, Zometa)? ______________________________________________________________YesNoHave you ever taken any of these appetite suppressants: fenfluramine (Pondimin), dexphenfluramine (Redux), Phentermine (fen-phen)?__________________________________________________YesNoHave you ever been on steroid medications?__________________________________________YesNoDo you use recreational drugs?_____________________________________________________YesNoIf yes, type/frequency_______________________________________________________Do you have, or have you ever had, any of the following? Heart diseaseYesNoCongenital heart lesionYesNoRheumatic fever/Rheumatic heart diseaseYesNoHeart murmurYesNoHeart surgeryYesNoHeart valve repair/replacementYesNoAneurysm repairYesNoStent placementYesNoChest painYesNoStrokeYesNoEndocarditisYesNoHeart defibrillatorYesNoHeart pacemakerYesNoHigh blood pressureYesNoLow blood pressureYesNoSwollen ankles or feetYesNoRespiratory diseaseYesNoFainting or dizzinessYesNoHives or skin rashYes NoShortness of breathYesNoHay feverYesNoAsthmaYesNoDo you use an inhaler?YesNoCOPD or emphysema?YesNoDo you smoke cigarettes? Cigars? Pipe?YesNoIf yes, how much and how long?____________________________If quit, when?____________________________________________Do you use smokeless tobacco? YesNoIf yes, how much and how long?_____________________________If quit, when?_____________________________________________Persistent cough or cough that produces bloodYesNoTuberculosisYesNoSinus problemsYesNoDo you consume alcohol?YesNoIf yes, type/frequency______________________________________Liver diseaseYesNoHepatitis-A, B or CYesNoJaundiceYesNoStomach ulcerYesNoInflammatory bowel disease (Crohn’s, UC)YesNoDiabetesYesNoHypoglycemiaYesNoKidney diseaseYesNoOrgan transplantationYesNoSplenectomyYesNoBlood disorderYesNoProlonged/abnormal bleedingYesNoHemophiliaYesNoAnemiaYesNoSickle cell diseaseYesNoThyroid diseaseYesNoArthritis/Joint painYesNoAutoimmune diseaseYesNoRheumatoid arthritisYesNoProblems with your immune systemYesNoSeizure disorderYesNoJoint replacement? When?_________________YesNoPersistent diarrhea or recent weight lossYesNoPersistent swollen glands in neckYesNoSexually transmitted diseaseYesNoHIV positiveYesNoAIDSYesNoBlood TransfusionYesNoTumors or growthsYesNoCancerYesNoChemotherapyYesNoRadiationYesNoGlaucomaYesNoMental IllnessYesNoDepressionYesNoAnxiety disorderYesNoBipolar disorderYesNoEating disorderYesNoAlzheimer’s diseaseYesNoAre there any other diseases/conditions about which we need to be informed?WOMEN ONLYAre you pregnant?YesNoDo you anticipate becoming pregnant?YesNoDo you use a contraceptive?YesNoAre you nursing?YesNoI certify that I have read and understand all of the above. I acknowledge that my questions, if any, about the above inquires have been answered to my satisfactions. I will not hold Dr. Hanlon or any member of her staff responsible for any errors or omissions that I may have made in the completion of this form. _________________________________________________________________________ ____________________Signature of patient or guardianDateI, the undersigned, agree to pay in full those amounts charged by Mary Ann Hanlon, Inc. for services rendered to me or any member of my immediate family. I understand and agree that what my insurance company does not pay is my responsibility. I understand and agree that I will be responsible for check fees for returned checks (whether or not written or tendered by me). I further understand and agree that any amounts owed are due within the 30 day period stated, herein, unless financial arrangements in writing have been made in advance. _________________________________________________________________________ ______________________Signature of patient or guardianDate ................
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