Confidential Dental/Medical Questionnaire

CONFIDENTIAL DENTAL/MEDICAL QUESTIONNAIRE FOR THE DENTAL OFFICE OF DR. MARY ANN HANLON

Date______Name______Address______City______State______Zip Code______Home Ph______Cell Ph______Work Ph______E mail address______Preferred method of contact______Birth Date___/___/______Sex M F SSN______-______-______Marital Status S M D W Other Occupation______Height______Weight______Blood Pressure______Emergency contact______If you are completing this form for the patient, what is your relationship to the patient? ______

Primary Dental Insurance Information: Company Name______Company Address______City______State______Zip Code______Employee______Employer______Employee SSN______-______-______Employee Birth Date______/______/______

Secondary Dental Insurance Information: Company Name______Company Address______City______State______Zip Code______Employee______Employer______Employee SSN______-_____-______Employee Birth Date______/______/______

DENTAL INFORMATION

Dentist______Referred by______Reason for referral______Date of most recent dental examination_____/______/______How often do you get your teeth professionally cleaned______Please describe your personal oral hygiene routine______

Please describe any concerns you have with your mouth ______Does the idea of periodontal treatment make you anxious? Y N If yes, please explain:

______Do you have bleeding gums, bad taste in your mouth or mouth odor? Yes No Have you had periodontal treatment in the past? Yes No Does food wedge in between your teeth? Yes No Is your mouth frequently dry? Yes No Do you have a mouth breathing or snoring habit? Yes No Do you clench or grind your teeth? Yes No DENTAL INFORMATION CONTINUED Have you ever had orthodontic treatment? If yes, when? ______Yes No Have you ever had any serious problem with previous dental treatment? Yes No If yes, please explain______

MEDICAL INFORMATION Which describes your general health: Excellent Good Fair Poor My last physical examination was on______Please provide the names and contact information of your physician(s): ______Please explain any serious illnesses, hospitalizations and/or surgeries you have had: ______Please list all herbal supplements, nutritional supplements, prescription- and over the counter medications you are taking and the doses: ______Please circle any/all of the following to which you have had a reaction: local anesthetics Penicillin or other antibiotics sulfa drugs aspirin iodine latex codeine or other narcotics barbiturates/sedatives/sleeping pills any metals other Please explain: ______Have you ever been treated with any of the following bisphosphonate drugs (Actonel, Aredia, Boniva, Fosamax, Zometa)? ______Yes No Have you ever taken any of these appetite suppressants: fenfluramine (Pondimin), dexphenfluramine (Redux), Phentermine (fen-phen)?______Yes No Have you ever been on steroid medications?______Yes No Do you use recreational drugs?______Yes No If yes, type/frequency______

Do you have, or have you ever had, any of the following? Heart disease Yes No Congenital heart lesion Yes No Rheumatic fever/Rheumatic heart disease Yes No Heart murmur Yes No Heart surgery Yes No Heart valve repair/replacement Yes No Aneurysm repair Yes No 2 Stent placement Yes No Chest pain Yes No Stroke Yes No Endocarditis Yes No

Heart defibrillator Yes No Heart pacemaker Yes No High blood pressure Yes No Low blood pressure Yes No Swollen ankles or feet Yes No Respiratory disease Yes No Fainting or dizziness Yes No Hives or skin rash Yes No Shortness of breath Yes No Hay fever Yes No Asthma Yes No Do you use an inhaler? Yes No COPD or emphysema? Yes No Do you smoke cigarettes? Cigars? Pipe? Yes No If yes, how much and how long?______If quit, when?______Do you use smokeless tobacco? Yes No If yes, how much and how long?______If quit, when?______Persistent cough or cough that produces blood Yes No Tuberculosis Yes No Sinus problems Yes No Do you consume alcohol? Yes No If yes, type/frequency______Liver disease Yes No Hepatitis-A, B or C Yes No Jaundice Yes No Stomach ulcer Yes No Inflammatory bowel disease (Crohn’s, UC) Yes No Diabetes Yes No Hypoglycemia Yes No Kidney disease Yes No Organ transplantation Yes No Splenectomy Yes No Blood disorder Yes No Prolonged/abnormal bleeding Yes No Hemophilia Yes No Anemia Yes No Sickle cell disease Yes No Thyroid disease Yes No Arthritis/Joint pain Yes No Autoimmune disease Yes No Rheumatoid arthritis Yes No Problems with your immune system Yes No Seizure disorder Yes No 3 Joint replacement? When?______Yes No Persistent diarrhea or recent weight loss Yes No Persistent swollen glands in neck Yes No Sexually transmitted disease Yes No HIV positive Yes No AIDS Yes No Blood Transfusion Yes No Tumors or growths Yes No Cancer Yes No Chemotherapy Yes No Radiation Yes No Glaucoma Yes No Mental Illness Yes No Depression Yes No Anxiety disorder Yes No Bipolar disorder Yes No Eating disorder Yes No Alzheimer’s disease Yes No

Are there any other diseases/conditions about which we need to be informed?

WOMEN ONLY Are you pregnant? Yes No Do you anticipate becoming pregnant? Yes No Do you use a contraceptive? Yes No Are you nursing? Yes No

I certify that I have read and understand all of the above. I acknowledge that my questions, if any, about the above inquires have been answered to my satisfactions. I will not hold Dr. Hanlon or any member of her staff responsible for any errors or omissions that I may have made in the completion of this form.

______Signature of patient or guardian Date

I, the undersigned, agree to pay in full those amounts charged by Mary Ann Hanlon, Inc. for services rendered to me or any member of my immediate family. I understand and agree that what my insurance company does not pay is my responsibility. I understand and agree that I will be responsible for check fees for returned checks (whether or not written or tendered by me). I further understand and agree that any amounts owed are due within the 30 day period stated, herein, unless financial arrangements in writing have been made in advance.

______Signature of patient or guardian Date