Olde Naples Denise Gay, DDS,- z" olde naples periodontics denise c. gay, dds,m.d.e‘5. specializing...
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- Z" Olde Naples periodontics Denise C. Gay, DDS, M.D.e‘5. SPECIALIZING 1N PERIODONTICS 8t DENTAL IMPLANTS NEW PATIENT INFORMATION NAME DATE LOCAL ADDRESS CITY ST ZIP PHONE ( ) CELL ( ) ' EMAIL OCCUPATION AND EMPLOYER BUSINESS ADDRESS CITY ST ZIP BUSINESS PHONE ( ) SOCIAL SECURITY # AGE BIRTHDATE / / MARITAL STATUS SPOUSE 0R GUARDIAN NAME SPOUSE on GUARDIAN PHONE ( ) NAME OF DENTIST HOW LONG? NAME OF PHYSICIAN HOW LONG? BY WHOM WERE YOU REFERRED? DO YOU HAVE DENTAL INSURANCE? Please answer the following questions by circling yes or no. Though some of the questions may seem unrelated to your gum condition, they are all essential in assessing your general health status and resis‑ tance, and therefore are important considerations in the diagnosis and treatment of periodontal disease. DATE OF YOUR LAST DENTAL CLEANING DATE OF YOUR LAST PHYSICAL EXAM YES NO ARE YOU BEING TREATED FOR ANY MEDICAL PROBLEM? If so, What? YES NO HAVE YOU HAD ANY SERIOUS ILLNESS OR O?ERATION? If so, What and When? YES NO HAVE YOU HAD EXCESSIVE BLEEDING REQUIRING SPECIAL TREATMENT? YES NO ARE YOU ALLERGIC TO ANY DRUGS OR MEDICATIONS? Examples: Aspirin, Penicillin, other Antibiotics, Local Anesthetics, (Novocaine), Codeine, Barbiturates, Sleeping pllls, Narcotics, Alcohol. YES NO HAVE YOU BEEN TOLD TO AVOID ANY DRUGS OR MEDICATIONS? YES NO DO YOU CONSUME ALCOHOL? If so, how many glasses daily? YES NO DO YOU TAKE ANY RECREATIONAL DRUGS OVER
Transcript of Olde Naples Denise Gay, DDS,- z" olde naples periodontics denise c. gay, dds,m.d.e‘5. specializing...
- Z" Olde Naples periodonticsDenise C. Gay, D D S , M.D.e‘5.
S P E C I A L I Z I N G 1 NP E R I O D O N T I C S 8 t D E N TA L I M P L A N T S
NEW PATIENT INFORMATION
NAME DATE
LOCAL ADDRESS CITY ST ZIP
PHONE ( ) CELL ( ) '
OCCUPATION AND EMPLOYER
BUSINESS ADDRESS CITY ST ZIP
BUSINESS PHONE ( ) SOCIAL SECURITY #
AGE BIRTHDATE / / MARITAL STATUS
SPOUSE 0R GUARDIAN NAME
SPOUSE on GUARDIAN PHONE ( )
NAME OF DENTIST HOW LONG?
NAME OF PHYSICIAN HOW LONG?
BYWHOM WERE YOU REFERRED?
DOYOU HAVE DENTAL INSURANCE?
Please answer the following questions by circling yes or no. Though some of the questions may seemunrelated to your gum condition, they are all essential in assessing your general health status and resis‑tance, and therefore are important considerations in the diagnosis and treatment of periodontal disease.
DATE OF YOUR LAST DENTAL CLEANINGDATE OF YOUR LAST PHYSICAL EXAM
YES NO ARE YOU BEING TREATED FOR ANY MEDICAL PROBLEM?If so, What?
YES NO HAVE YOU HAD ANY SERIOUS ILLNESS OR O?ERATION?If so, What and When?
YES NO HAVE YOU HAD EXCESSIVE BLEEDING REQUIRING SPECIAL TREATMENT?YES NO ARE YOU ALLERGIC TO ANY DRUGS OR MEDICATIONS? Examples: Aspirin, Penicillin, other
Antibiotics, Local Anesthetics, (Novocaine), Codeine, Barbiturates, Sleeping pllls, Narcotics,Alcohol.
YES NO HAVE YOU BEEN TOLD TO AVOID ANY DRUGS OR MEDICATIONS?YES NO DO YOU CONSUME ALCOHOL? If so, how many glasses daily?YES NO DO YOU TAKE ANY RECREATIONAL DRUGS
OVER
YESYESYESYESYESYESYESYESYESYESYESYESYESYESYESYESYES
YESYESYES
YESYESYES
YES
YES
YES
YES
'NONONONONONONONONONONONONONONONONO
NONONO
NONONO
NO
NO
NO
NO
HAVEYOUHADANY OFTHE FOLLOWINGCONDITIONS?
HEART CONDITION, HEART MURMUR, IMPLANT, HEARTATTACK, OR STROKE?RHEUMATIC FEVER?HIGHOR LOW BLOOD PRESSURE?BLOOD DISORDERS?EPILEPSYOR SEIZURES?ALLERGIES, SINUS TROUBLE, OR HAY FEVER?LUNG DISORDER (TS , ASTHMA, EMPHYSEMA, OROTHERS)?KIDNEY DISORDER (NEPHRITIS, STONES, OROTHERS)?LIVER DISORDERS (HEPATITIS, CIRRHOSIS, JAUNDICE, OROTHERS)?VENEREAL DISEASE?ARTHRITIS ORRHEUMATISM,ARTIFICIAL JOINT? WHERE?STOMACH TROUBLE (ULCERS, COLITIS, OR OTHERS)?EYETROUBLE (GLAUCOIVIA OROTHERS)?RADIATION OR COBALT TREATMENT?DIABETES?IS ANYONE IN YOUR BLOOD RELATIVE FAMILY DIABETIC? RELATION?OSTEOPOROSIS OROSTEOPENIA?IF 80, ARE YOU TAKINGANYMEDICATION? “HAVEYOU EVER BEENTESTED FOR HIV/AIDS?IF SO, HAVEYOU EVERTESTED POSITIVE?DOYOU HAVEANY CONDITION ORPROBLEMNOT LISTEDABOVE THAT YOU THINKWE SHOULD KNOWABOUT?EXPLAIN:
ARE YOU UNDER STRESS? SOCIAL / BUSINESS / MARITAL / FINANCIALDOYOU USETOBACCO INANY FORM? HOWMUCH? PERDAYHAVEYOU EXPERIENCEDANY UNFAVORABLE REACTIONSTO PREVIOUS DENTALTREATMENT?ARE YOU AWARE OI: CLENCHING, GRITTING, ORGRINDINGYOUR TEETH?WHEN?HAVEYOU EVER BEENTREATED FOR PERIODONTAL DISEASE BEFORE?WHENAND BYWHOM?ARE YOU TAKING ANY DRUGS ORMEDICATIONS?PLEASELIST:
WOMEN ONLYYES NO ARE YOU TAKING ORAL OONTRACEPTIVES?
ARE YOU PREGNANT? YES NO HAVEYOU REACHEDMENORAUSE?TOThe best of my kOOWISOgS, The OIOOVO Informai‘iOn IScorrect.PATIENTS SIGNATURE DATE
OR IFA MINOR, SIGNATURE OF LEGAL GUARDIAN
THANK YOU
