Patient Info Form - Dr. Keith A. Gilbert

Patient Name*
First
DOB:*
Sex:*
Age:*
Home Address*
City*
State*
Zip*
Home phone:*
Cell:*
E-Mail:*
SS#:*
Employer:*
Bus. Phone:*
Marital Status*
- Single
- Married
- Divorced
- Other
Spouse Name:*
First
Spouse Phone Number:*
Emergency Phone# (other than spouse):*
Primary Dental Insurance:*
ID #:*
Group#:*
Secondary Dental Insurance:*
ID #:*
Group#:*
Subscriber’s Name:*
First
Date of Birth:*
SS#:*
Name of Medical Physician:
First
Date of last visit to medical physician:
Name of Previous Dentist:
First
Date of last cleaning:
Referred to us by:
Preferred Method of Contact?
- Home
- Cell
- Email
DENTAL HEALTH HISTORY
Are you apprehensive about dental treatment?
- NO
- YES
Have you had problems with previous dental treatment?
- NO
- YES
Do you gag easily?
- NO
- YES
Do you wear Dentures?
- NO
- YES
Does food catch between your teeth?
- NO
- YES
Do you have difficulty in chewing your food?
- NO
- YES
Do you chew on only one side of your mouth?
- NO
- YES
Do you avoid brushing because of pain?
- NO
- YES
Do your gums bleed easily?
- NO
- YES
Do you bleed when you floss?
- NO
- YES
Do your gums feel swollen or tender?
- NO
- YES
Have you ever noticed slow-healing sores about your mouth?
- NO
- YES
Are your teeth sensitive?
- NO
- YES
Do you feel twinges of pain when your teeth come in contact with
- Hot foods or liquids?
- Cold foods or liquids?
- Sours?
- Sweets?
Are you dissatisfied with the appearance of your teeth?
- NO
- YES
Do you prefer to save your teeth?
- NO
- YES
Do you want complete dental care?
- NO
- YES
How often do you brush?
How often do you floss?
Does your jaw make noise so that it bothers you?
- NO
- YES
Do you clench or grind your jaw frequently?
- NO
- YES
Does your jaw ever feel tired?
- NO
- YES
Does your jaw get stuck so that you can’t open it freely?
- NO
- YES
Does it hurt when you chew or open wide to take a bite?
- NO
- YES
Do you have earaches or pain in front of ears?
- NO
- YES
Do you have any jaw symptoms or headaches upon awakening in the morning?
- NO
- YES
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
- NO
- YES
Do you find jaw pain or discomfort extremely frustrating or depressing?
- NO
- YES
Do you take medications or pills for discomfort (pain relievers, muscle relaxants, antidepressants?
- NO
- YES
Do you have a temporomandibular (jaw) disorder (TMD)?
- NO
- YES
Do you have pain in the face, cheeks, jaws, joints, throat or temple?
- NO
- YES
Are you able to open your mouth as far as you want?
- NO
- YES
Are you aware of an uncomfortable bite?
- NO
- YES
Have you had a blow to the jaw (trauma)?
- NO
- YES
Have you had your wisdom teeth removed?
- NO
- YES
MEDICAL HEALTH HISTORY
Do you have, or have you had, any of the following?
Health Problems
- Chest Pain
- Shortness of breath
- Blood pressure problem
- Heart murmur
- Heart valve problem
- Taking heart medication
- Rheumatic fever
- Pacemaker
- Artificial heart valve
Blood Problems
- Easy Bruising
- Frequent nosebleeds
- Abnormal bleeding
- Blood disease (anemia)
- Ever require a blood transfusion?
Allergy Problems
- Hay fever
- Sinus Problems
- Skin rashes
- Taking allergy medication
- Asthma
Intestinal Problems
- Ulcers
- Weight gain or loss
- Special diet
- Constipation/Diarrhea
- Kidney or bladder problems
Bone or Joint Problems
- Arthritis
- Back or neck pain
- Joint replacement
- Osteoporosis/Osteopenia
- Do you take medications for Osteoporosis/ Osteopenia?
If so, please list medications
Fainting Spells, Seizures, or Epilepsy
- NO
- YES
Stroke
- NO
- YES
Frequent or severe headaches
- NO
- YES
Thyroid problems
- NO
- YES
Persistent cough or swollen glands
- NO
- YES
Diabetes
- NO
- YES
Urinate more than 6 times a day
- NO
- YES
Thirsty or mouth is dry much of time
- NO
- YES
Family history of diabetes
- NO
- YES
Tuberculosis or other respiratory disease
- NO
- YES
Do you drink alcohol?
- NO
- YES
If so, how much?
Do you smoke?
- NO
- YES
If so, how much?
Hepatitis, jaundice, or liver trouble
- NO
- YES
HIV-positive/AIDS
- NO
- YES
Glaucoma
- NO
- YES
Do you wear contact lenses?
- NO
- YES
History of head injury?
- NO
- YES
Epilepsy or other neurological disease?
- NO
- YES
History of alcohol or drug abuse?
- NO
- YES
Do you have any disease, condition, or problem previously that you feel we should know about?
- NO
- YES
If so, please describe:
During the past 12 months, have you taken any of the following?
Antibiotics or sulfa drugs
- NO
- YES
Anticoagulants (e.g., Coumadin)
- NO
- YES
High blood pressure medicine
- NO
- YES
Tranquilizers
- NO
- YES
Insulin, Orinase, or similar drug
- NO
- YES
Aspirin
- NO
- YES
Digitalis or drugs for heart trouble
- NO
- YES
Nitroglycerin
- NO
- YES
Cortisone (steroids)
- NO
- YES
Natural remedies
- NO
- YES
Nonprescription drug/supplements
- NO
- YES
Please list any medications you are presently taking
WOMEN
Are you taking contraceptives?
- NO
- YES
Are you pregnant?
- NO
- YES
If so, expected delivery date: ______________
- NO
- YES
Are you nursing?
Have you reached menopause?
- NO
- YES
If so, do you have any symptoms?
- NO
- YES
Are you allergic to any of the following?
Local anesthetics (“Novocaine”)
- NO
- YES
Penicillin or other antibiotics
- NO
- YES
Sulfa drugs
- NO
- YES
Barbiturates, sedatives, or sleeping pills
- NO
- YES
Aspirin, Acetaminophen, or Ibuprofen
- NO
- YES
Codeine, Demerol, or other narcotics
- NO
- YES
Reaction to metals
- NO
- YES
Latex or rubber dam
- NO
- YES
Other
Notes:
Office Policies and Procedures
In order to better serve you in the most consistent, efficient and transparent way possible, we have established the following office policies. Please Check Each Box to indicate that you have read and understood them.
Office Policies and Procedures*
- Payment and/or copayment is required in full at the time services are rendered. If you have dental insurance coverage, please be advised that the co-payment requested for services rendered is only an estimate based on information that was given to us by your insurance company.
- If you have any questions about your insurance coverage, please let us answer them before treatment begins. Otherwise, the assumption will be that you are familiar with your dental plan coverage and limitations.
- The doctor and hygienist have reserved your appointment time slot ESPECIALLY for you. A minimum of 24 hours’ notice is required for all appointment changes or cancellations in order to avoid a $50 broken appointment fee.
- There will be a $35.00 fee for each returned (bad) check that we receive.
- We are not a participating Blue Cross/Blue Shield Dentist. Our office will be happy to submit a claim to Blue Cross/Blue Shield for your reimbursement; however, payment will be expected at the time services are rendered,.

DENTAL HEALTH HISTORY

MEDICAL HEALTH HISTORY

During the past 12 months, have you taken any of the following?

WOMEN

Are you allergic to any of the following?

Office Policies and Procedures