Periodontal Patient Information Questionnaire

Periodontal Patient Information Questionnaire
Coast Periodontics & Laser Surgery
Lynn C. Sayre-Carstairs, DMD, Inc.
info@coastperiodontics.com
Patient Name (legal name):
Patient Preferred (nickname) name:
Age:
Date of Birth

- Month - Day Year
Date
Male Female
Single Married Other Minor

Mailing Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone:
Mobile Phone:
Business Phone:
Best way to contact you?
What days and times are best for an appointment?
Social Security #:
Email:
example@example.com
Occupation:
Family Dentist:
City:
How Long:
Last Cleaning:
Emergency Contact or (Parent or Guardian if minor):
Phone:
Oral History
Present Dental Complaint?
Do you have an unpleasant taste or odor in your mouth?

Yes No
Are your teeth sensitive?

Yes No
Do your gums bleed? If so, when?

Yes No
Have you ever had orthodontic treatment (braces)

Yes No
Are your gums sore or swollen?

Yes No
Does your jaw click or pop?

Yes No
Do you clench or grind your teeth?

Yes No
Have you had periodontal treatment previously? By whom?
Health History
Height:
Weight:
How is your general health?

GOOD FAIR POOR
Are you now being treated or have you been treated within the last year by a physician?

Yes No
Family Physician:
City:
Last Exam:
Have you ever had any surgery?

Yes No
Do you have any artificial joints?

Yes No
Are you now taking any medication, drugs, or pills? INCLUDING ASPIRIN, VITAMINS & HERBS

Yes No
If yes, please list all medications:
Have you taken cortisone/steroids in the last year?

Yes No
Have you ever experienced a reaction to any of the following?
Aspirin

Yes No
Penicillin

Yes No
Codeine

Yes No
Latex

Yes No
Iodine

Yes No
Sleeping Pills

Yes No
Dental Anesthetics (Novocain)

Yes No
Antibiotics (which ones)

Yes No
Others, Misc.

Yes No
Have you ever had?
Asthma

Yes No
Anemia or any abnormal blood counts

Yes No
Arthritis / Rheumatism

Yes No
Bleeding Problems

Yes No
Convulsions

Yes No
Diabetes (sugar in blood)

Yes No
Epilepsy or Seizure disorders

Yes No
Glaucoma or Cataracts

Yes No
Heart Trouble

Yes No
Heart Murmur or Mitral Valve Prolapse

Yes No
High Blood Pressure

Yes No
Hepatitis (liver disease)

Yes No
Intestinal Disorder

Yes No
Jaundice (yellow skin or eyes)

Yes No
Kidney Disease

Yes No
Lung Disease

Yes No
Osteoporosis

Yes No
Rheumatic Fever

Yes No
Radiation / Chemo treatment

Yes No
Radiation / Chemo treatment

Yes No
Stroke

Yes No
Tumor or Growth

Yes No
Tuberculosis

Yes No
Thyroid or Parathyroid trouble

Yes No
Ulcers or Stomach problems

Yes No
Do you consider yourself a nervous person?

Yes No
Do you get up often at night to urinate?

Yes No
Has anyone in your family had diabetes?

Yes No
Have you tested positive for HIV?

Yes No
Do you have AIDS or PREAIDS?

Yes No
Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?

Yes No
Have you ever taken Bisphosphonates for osteoporosis, chemo therapy, multiple myeloma or other cancers (Fosamax, Actonel, Boniva, Aredia or Zometa)?

Yes No
Would you like to speak to the doctor privately about any problem?

Yes No
Patient / Legal Guardian Signature

Clear
Date

- Month - Day Year
Date
Doctor's Signature

Clear
Date

- Month - Day Year
Date

(For Office Use Only)

Clinical Information
B.P.
Pulse
Lymph Nodes
Buccal Mucosa
Tongue
Alveolar Ridges
Lips
Floor of Mouth
Palate
Freni
Examination:
Diagnosis
Gingivitis
Periodontitis
Periapical Periodontitis
Other
Occlusion
Centric
R. Working
L. Working
Protrusive
Alignment
Slide
L. Non-Working
R. Non-Working
TMJ
Opening
Overbite
Overjet
Abrasion
Fremitus
Should be Empty: