UCBA Dental Hygiene New Patient Form
Name
First Name
Last Name
Middle Initial
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
M # (UC School ID)
Date of Birth
Military ID
Emergency Contact/Relationship
Relationship to patient:
Phone Number
-
Area Code
Phone Number
Current/Previous Dentist
Dentist Phone #
-
Area Code
Phone Number
Date of last bitewing xray series:
-
Month
-
Day
Year
Date
Date of last full mouth xray series:
-
Month
-
Day
Year
Date
Date of last panorex xray:
-
Month
-
Day
Year
Date
Physician
Physician Phone #
-
Area Code
Phone Number
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Current Conditons
Do you have any of the following diseases or problems?
Active tuberculosis
YES
NO
Persistent cough greater than 3 weeks
YES
NO
Cough that produces blood
YES
NO
Been exposed to anyone with tuberculosis
YES
NO
If patient answers yes to any of these questions, please stop and inform medical staff
Are you under the care of a physician? If yes, list physician name and why
Are you in good health?
YES
NO
Has there been any change to your general health within the past year?
YES
NO
Date of last physical exam
Have you had a serious illness or been hospitalized in the past 5 years?
YES
NO
If yes, why?
Are you taking or have you recently taken any prescription or over the counter medicines?
YES
NO
Are you taking or have you recently taken any prescription or over-the-counter medications? If yes, please list all including name, purpose for medication, dosage and time of day taken:
Do you wear contact lenses?
YES
NO
Do you use controlled substances (drugs)?
YES
NO
If yes,
Do you use tobacco (smoking, snuff, chew?
YES
NO
If yes, what form and how much per day?
Do you drink alcoholic beverages?
YES
NO
If yes, how much alcohol did you drink in the past 24 hours? How much in a week?
How interested are you in stopping?
VERY
SOMEWHAT
NOT INTERESTED
NOT APPLICABLE
Have you had an orthopedic total join (hip, knee, elbow, finger) replacement?
YES
NO
If yes, include date, type of replacement and any complications. Please provide orthopedic surgeon's name and phone number.
Are you taking or planning to take an antiresorptive agent (like Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia)?
YES
NO
If yes,
Since 2001, have you or will you be treated with an antiresorptive agent (Arecia, Zometa, XGEVA)?
YES
NO
If yes, for which condition
Bone Pain
Hypercalcemia
Paget's Disease
Multiple Myeloma
Metastatic Cancer
If yes, date treatment began.
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WOMEN ONLY
Are you taking birth control pills or hormone replacement?
YES
NO
Pregnant or trying to get pregnant?
YES
NO
If yes, how many weeks?
Nursing?
YES
NO
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Allergies?
Local Anesthetics
Barbiturates, sedatives, sleeping pills
Codeine or other narcotics
Latex (rubber)
Hay Fever
Food
Penicillin or other anibiotics
Sulfa drugs
Metals
Iodine
Animals
Other
If yes to any above, please specify cause and type of reaction.
Please indicate if you have or had any of the following diseases or problems
Cardiovascular disease
Congestive heart failure
Low blood pressure
Mitral valve prolapse
Rheumatic heart disease
Blood transfusion
Arthritis
Systemic lupus erythematous
Emphysemia
Chest pain upon exertion
Eating disorder
G.E. reflux/persistent heartburn
stroke
Epilepsy
Sleep disorder
Recurrent infection
Osteoporosis
Severe or rapid weight loss
Angina
Heart attack
High blood pressure
Pacemaker
Abnormal bleeding
Hemophilia
Autoimmune disease
Asthama
Sinus trouble
Chronic pain
Malnutrition
Ulcers
Glaucoma
Fainting spells or seizures
Do you snore?
Kidney problems/Dialysis
Persistent swollen glands in neck
Sexually transmitted disease
Damage heart valves
Arteriosclerosis
Heart murmur
Other congenital heart defects
Rheumatic fever
Anemia
AIDS or HIV infection
Rheumatoid arthritis
Bronchitis
Cancer/Chemotherapy/Radiation treatment
Diabetes Type 1 or 2
Gastrointestinal disease
Thyroid problems
Hepatitis, Jaudice or Liver disease
Neurological disorders
Mental Health disorder
Night sweats
Severe headaches/migraines
Excessive urination
Herpes/cold sores/fever blisters
Other
If yes to any above, please specify additional information that may be beneficial such as dates, types, or controlled conditions.
If yes to any of the following CHD conditions, antibiotic prophylaxis is recommended. Consult a physician
Artificial (prosthetic) heart valve
previous infective endocarditis
damaged valves in transplanted heart
CHD: unrepaired, cyanotic CHD
CHD: reapaired (completely) in last 6 month
CHD: repaired CHD with residual defects
Has a physician or previous dentist recommend that you take antibiotics prior to dental treatment?
YES
NO
Do you have any diseases, conditions not listed that you think I should know about? If yes, please explain.
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Do you grind your teeth?
Yes
No
Do you bite your cheek?
Yes
No
Do you tongue thrust?
Yes
No
Are you a mouth breather?
Yes
No
Are you bulimic/anorexic?
Yes
No
Do you smoke cigars or cigarettes?
Yes
No
Do you smoke a pipe?
Yes
No
Do you bite your nails often?
Yes
No
Do you use smokeless tobacco?
Yes
No
Do you suck your thumb/finger?
Yes
No
Do you use a toothpick often?
Yes
No
Do you chew gum often?
Yes
No
Do you eat candy often?
Yes
No
Do you drink pop often?
Yes
No
How often do you brush your teeth?
How often do you floss?
What kind of toothpaste do you use?
Do you use mouthwash? If yes, what kind?
Are you experiencing any pain in your mouth? If so, where?
Are your teeth sensitive to hot/cold? If yes, where at in the mouth?
Are your teeth sensitive to biting or chewing? If yes, where at in the mouth?
Are your teeth sensitive to sweets? If yes, where at in the mouth?
Have you ever had orthodontic treatment? (braces) If yes, what years?
Have you ever had a bite plate or guard? If yes, when and what for?
Have you ever had periodontic treatment? If yes, when?
Have you ever had oral surgery? (example, removal of wisdom teeth) If yes, when and what for?
Have you ever had a serious injury to your mouth/head? If yes, briefly describe.
How often do you normally go to the dentist?
When did you last go to the dentist? Were there any complications?
Do you participate in sports?
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