Sydenham Family Dental | Biological & Comprehensive Dentistry

Opening Hours: Monday-Thursday: 8:00am – 4:30pm
Open House: on Friday April 26, 3:00 PM – 6:00 Pm
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Sydenham Family Dental

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New Patient Medical History Form














    Patient Guardian Information

    If the patient is a minor, please fill out the box below:





    Insurance Information

    We are a "fee for service" office and require payment at the time of service, therefore, we will gladly provide you with any information required each visit to make claim to your insurance company for reimbursement. Please let us know if you have any questions.







    I certify that the information in this document is correct to the best of my knowledge.



    Medical History

    Please answer the following questions as completely and accurately as you can. Also, please be as detailed as possible providing additional information you think is important. If you have any questions about this form, or your upcoming appointment, contact our office for assistance.

    Please select yes or no. If yes, please explain on the lines provided.

    1 Do you have a current medical problem?

    2 Have you been told you have a heart murmur?

    3 Do you have any heart problems? What kind?

    4 4. Do you have high or low High Blood Pressure blood pressure? How is it controlled?

    5 Have you had rheumatic fever? When?

    6 Have you had pain in your chest or shortness of breath?

    7 Do your ankles swell?

    8 Has you physician ever told you that you are anemic?

    9 Have you ever had a stroke? When?

    10 Have you ever had epilepsy?

    11 Do you have diabetes? Is it controlled?

    12 Do you have fainting or dizzy spells?

    13 Do you feel like your sense of balance has changed?

    14 Do you have headaches? How often? Where?

    15 Do you take Aspirin, Advil, Tylenol or another pain reliever? How often?

    16 Have you been advised not to take any medication? What?

    17 Do you have asthma or hay fever? How is it controlled?

    18 Have you ever had tuberculosis? When?

    19 Have you ever had glaucoma? When?

    20 Have you ever had hepatitis? When?

    21 Do you have arthritis? How is it controlled?

    22 Have you ever had a tumor or cancer? How was it treated?

    23 Have you ever had any major surgeries? What kind?

    24 Have you ever been injured in an accident? When?

    25 Have you ever had a severe blow to the head? When?

    26 Are your hands and/or feet cold? How often?

    27 Is your diet medically supervised? For what purpose?

    28 Do you have difficulty swallowing

    29 Do you have a feeling of something stuck in your throat?

    30 Do you ever have any facial pain or pressure? Where?

    31 Do you ever have any pain or pressure behind your eyes?

    32 Are you aware of stiff neck muscles? How often?

    33 Have you been in traction for a neck injury? When?

    34 Have you ever had or been advised to have neck surgery?

    35 Do you have back pain? Where?

    36 Do your ears feel itchy, stuffy or congested?

    37 Do you have difficulty with pain in your ears when changing altitude?

    38 Do your ears ring, buzz or hiss? How often?

    39 Have you noticed any changes in your hearing?

    40 Are you depressed?

    41 Do you have emotional or anxiety/nervous problems?

    42 Have you ever been treated for emotional or anxiety/nervous problems?

    43 Have you gained or lost weight within the last year? Which:

    44 Do you take more than one alcoholic drink per day? How many?

    45 Do you use tobacco? How much?

    46 Have you had any other serious illnesses, hospitalization or accidents? Please explain:

    Please list ALL medications, including supplements, and the dosage you are currently taking:

    Please list any allergies to any medications:

    Other allergies::

    Dental History

    47 When was your last dental visit?

    48 Have you been told that you have periodontal (gum) disease?

    49 Do you have any existing problems with your teeth? Describe:

    50 Is any dental treatment planned? Describe:

    51 Do you bite your nails?

    52 Have you ever had oral surgery?

    53 Have you lost any teeth? From what cause?

    54 Have the teeth been replaced? When?

    55 Have you ever had orthodontic treatment? When?

    56 Have you ever had extensive dental treatment? When?

    57 Is any part of your mouth sensitive to temperature, pressure, food or drink? Where?

    58 Do you wear dentures or partial dentures? Are they comfortable?

    TMJ History

    59 Do you ever have a burning or painful sensation in your mouth?

    60 Do you get popping, clicking, or grinding noises when you open or close?

    61 Do you ever awaken with an awareness of your teeth or jaws?

    62 Are you aware of clenching during the daytime? How often?

    63 Have you ever been told you grind your teeth during sleep?

    64 Do you have trouble opening your mouth widely?

    65 Does your jaw ever lock open or closed? How often?

    66 Do you feel your bite is different, unstable or uncomfortable?

    67 What professional advice or treatment have you had regarding your head, neck or facial pain?

    68 If you sought treatment for a TMJ problem, did it help?

    69 Do you or have you had any pain in any of the following areas?

    70 Do your jaw problems affect your ability to chew?

    71 Has your diet changed due to your jaw problems? Describe:

    Family History

    72 Do you have children? What are their ages?

    73 Current level of stress

    For Women

    74 Are you pregnant? Expected delivery date:

    75 Do you have a history of miscarriages? When?

    76 Have you reached menopause?

    Sleep, Snoring, and Apnea History

    77 Do you become easily fatigued? At what time of day?

    78 Do you have problems with insomnia?

    79 Do you sleep well? How long?

    80 Do you dream? How often?

    81 Do you have trouble falling asleep or staying asleep? Which:

    82 Do you snore or have you been told you do?

    83 Do you wake up with a headache?

    84 Have you had chronic sleepiness, fatigue or weariness that you can’t explain?

    85 Do you often fall asleep reading or watching television?

    86 Have you fallen asleep during the day against your will?

    87 Have you had to pull off the road while driving due to sleepiness?

    88 Have you been more irritable and short tempered?

    89 Have you felt that your memory and/or intellect is impaired?

    90 Have you been told that you stop breathing while asleep?

    91 About how many times per night do you wake up?

    92 What time do you normally go to bed? Get up in the morning?

    93 Of the hours you are in bed, about how many hours are you asleep?

    94 Do you have difficulty breathing through your nose?

    95 Do you have difficulty breathing through your nose?

    96 Have you been diagnosed or treated for a sleep disorder? When:

    97 Have any immediate family members been diagnosed or treated for a sleep disorder?

    98 Have you ever had an evaluation at a sleep center?

    Sleep cnter name

    Location

    Sleep Study Date

    99 What professional advice or treatment have you received about your snoring or sleep apnea?

    100 If you sought treatment for a sleep disorder, did it help?

    Sleep, Snoring, and Apnea History

    How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life recently.
    Use the following scale and choose the most appropriate number for each situation:

    0 = Would never doze

    1 = Slight chance

    2 = Moderate chance of dozing

    3 = High chance of dozing

    Sitting and reading

    Watching TV

    Sitting inactive in a public place (e.g. A theater or a meeting)

    As a passenger in a car for an hour without a break

    Lying down to rest in the afternoon when circumstances permit

    Sitting and talking to someone

    Sitting quietly after a lunch without alcohol

    In a car, while stopped for a few minutes in traffic

    CPAP Device

    If you have not worn a CPAP device, skip this section.

    Do you wear a CPAP device successfully during sleeping?

    How many hours per night do you wear your CPAP?

    Have you tried other therapies for your sleeping disorder? Please list other therapies (weight-loss attempts, smoking cessation, surgeries, appliances, etc.)

    CPAP Difficulties

    If you are unable to wear a CPAP device, please check below the reasons for your difficulty.

    Other

    Nutrition

    Which type of diet do you follow?

    How often do you eat fast food:

    Do you have any questions about diet & nutrition?

    Complaints For Seeking Treatment

    What are the chief complaints for which you are seeking treatment? Please order your chief complaints by number: 1 being the 1st or most important, 2 being the 2nd important, 3 being the 3rd less important, 4, 5, 6, etc. List only those that apply.

    Chief Complaint

    Order

    For Office Use Only

    Jaw clicking/popping

    Jaw joint noises

    Jaw locking

    Muscle twitching

    Limited mouth opening

    Dizziness

    Headaches

    Visual disturbances

    Jaw pain

    Facial pain

    Ear pain

    Back pain

    Eye pain

    Neck pain

    Shoulder pain

    Pain when chewing

    Throat pain

    Ear congestion

    Sinus congestion

    Ringing in the ears

    Fatigue

    Frequent heavy snoring

    Snoring which affects the sleep of others

    Significant daytime drowsiness

    Stop breathing when sleeping

    Difficulty falling asleep

    Gasping when waking up

    Nighttime choking spells

    Feeling unrefreshed upon waking

    Morning hoarseness







    Professional References

    To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to list your primary physician and other health practitioners. Please initial if you want us to send them a report from your visit.

    Family Physician





    Other





    Partner Survey

    To help us with a proper diagnosis and appropriate treatment plan, have your partner, if applicable and available, fill out this questionnaire regarding your sleep habits. This information is vitally important for Dr. Clinton to best evaluate your current condition. This is to be filled out by the patient's partner


    1 Do you witness your partner snoring?

    2 Do you witness your partner choking or gasping for breath during sleep?

    3 Does your partner pause or stop breathing during sleep?

    4 Does your partner fall asleep easily, if given the opportunity, during the day (normal wakeful hours)?

    5 Do you witness your partner clenching and/or grinding his/her teeth during sleep?

    6 Does the your partner refreshed upon waking?

    7 Do your partner sleep habits disturb your sleep?

    8 Does your partner sit up in bed, not awake?

    9 Please check those sleep habits of your partner that are disturbing to you:

    Sleeping Situations

    How likely is your partner to doze off or fall asleep in the following situations, in contrast to just feeling tired?

    Use the following scale and choose the most appropriate number for each situation:

    0 = Would never doze

    1 = Slight chance

    2 = Moderate chance of dozing

    3 = High chance of dozing

    Sitting and reading

    Watching TV

    Sitting inactive in a public place (e.g. A theater or a meeting)

    As a passenger in a car for an hour without a break

    Lying down to rest in the afternoon when circumstances permit

    Sitting and talking to someone

    Sitting quietly after a lunch without alcohol

    In a car, while stopped for a few minutes in traffic

    Office Policies

    Please take a moment to read our office policies and feel free to ask any questions you may have.

    Consent For Treatment

    I hereby authorize Sydenham Family Dental and designated staff to take x-rays, study models, photographs, electro-diagnostic studies and other diagnostic aids mutually agreed upon and deemed appropriate to make a thorough diagnosis

    Upon such diagnosis, I authorize Sydenham Family Dental and staff to perform all recommended treatment mutually agreed upon by me and to employ such professional assistance as required to provide proper care.

    I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

    I authorize the release of a full report of examination findings, diagnosis, treatment program and ongoing progress report to any referring dentist, physician, chiropractor or other health care professionals as indicated previously. I additionally authorize the release of any medical information to insurance companies for legal documentation to process predeterminations and claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.

    Financial Policy

    Payment is expected the day of your procedure as outlined verbally and/or in the written financial arrangement. We accept cash, Master Card/Visa Debit. For our patients carrying medical insurance, we do not accept assignment of benefits. However, we are happy to assist you with your insurance billing as a courtesy, though financial responsibility lies with you. Please ask our Patient Coordinators about your insurance issues

    I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received as agreed, I understand that a late charge of 1.5% on monthly balances will be added to my account and my account may be turned over for legal collection of any overdue amount. Our goal is to eliminate "billing surprises" so let us help you plan your treatment carefully by addressing your financial concerns before treatment begins.

    Appointments

    Should you need to cancel an appointment, we ask that you notify our office at least 24 business hours in advance. If you fail to cancel your appointment appropriately or do not show up for your scheduled appointment, you will be charged a broken appointment fee of $100

    I have read and understand the Sydenham Family Dental Consent for Treatment, Financial and Appointment policies. I have had all of my questions regarding these issues answered by a Patient Coordinator and agree to abide by these policies.