COAST PERIODONTICS

Periodontal Patient Information Questionnaire

Coast Periodontics & Laser Surgery
Lynn C. Sayre-Carstairs, DMD, Inc.
info@coastperiodontics.com

You information is safe! The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

Patient Name (legal name):

Patient Preferred (nickname) name:

Age:

Date of Birth

Date

Male Female

Single Married Other Minor

Mailing Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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

Doctor's Signature

Clear

Date