James P Gagliardi DDS - Fircrest Dental Arts / (253)564-2570
Patient Information
Simply print out these pages and bring them to your next appointment. Thank you
| Patient name:_____________________________ | Date of birth:__________ |
| Home address:____________________________ | City/State:__________________Zip:_________ |
| Billing address (if different):__________________ | City/State:__________________Zip:_________ |
| Home phone:______________________________ | Driver's license #:_____________ _ State:______ |
| Work phone:______________________________ | Employer/Occupation:________________ |
| SS#:_____________________________________ | Emergency number:__________________ |
| Primary dental insurance:____________________ | |
| Subscriber's name:_________________________ | Date of birth:_________ |
| Name of your physician:_____________________ | |
| address:____________________________ | E-mail Address:___________________________ |
| phone #:____________________________ | |
| date of last visit:______________________ | |
| Name of previous dentist:___________________ | |
| Date of last dental visit:_____________________ |
Dental Health History (please X your "yes" answers)
| 1. Are you apprehensive about dental treatment? | 16. How often do you brush?.............................. | ||||
| 2. Have you had problems with dental care? | 17. How often do you floss?................................. | ||||
| 3. Do you gag easily? | 18. Does your jaw make a bothersome noise? | ||||
| 4. Do you wear dentures? | 19. Do you frequently clench or grind your jaws? | ||||
| 5. Does food catch between your teeth? | 20. Do your jaws ever feel tired? | ||||
| 6. Do you have difficulty with chewing? | 21. Does your jaw ever get stuck or stiff? | ||||
| 7. Do you chew only on one side of your mouth? | 22. Do you have earaches? | ||||
| 8. Does brushing your teeth hurt? | 23. Do you have headaches/pain when you awake? | ||||
| 9. Do your gums bleed easily? | 24. Do you take medication for pain / discomfort? | ||||
| 10. Do your gums bleed when you floss? | 25. Do you have tempromandibular (jaw) disorder? | ||||
| 11. Do your gums feel swollen or tender? | 26. Are you unable to open your mouth fully? | ||||
| 12. Do you ever get sores in / near your mouth? | 27. Are you aware of an uncomfortable bite? | ||||
| 13. Are your teeth sensitive? | 28. Have you ever suffered a jaw injury? | ||||
| 14. Do you take fluoride supplements? | 29. Are you a habitual gum chewer? | ||||
| 15. Do you feel your teeth could look nicer? | 30. Do you wear a night guard? | ||||
Medical Health History |
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| Heart Problems................................................... | Diabetes .......................................................... | ||||
| Chest pain........................................................... | Urinate more than 6 times a day .............. | ||||
| Shortness of breath............................................ | Thirsty or mouth is dry much of the time | ||||
| High blood pressure.......................................... | Family history of diabetes ........................ | ||||
| Low blood pressure........................................... | Tuberculosis or other respiratory disease | ||||
| Heart murmur..................................................... | Cancer / Tumor .............................................. | ||||
| Heart valve problem.......................................... | Do you drink alcohol? .................................. | ||||
| Taking heart medication................................... | How much? ................................................ | ||||
| Rheumatic fever................................................. | Do you smoke? .............................................. | ||||
| Pacemaker........................................................... | How much? ................................................ | ||||
| Artificial heart valve......................................... | Hepatitis, jaundice, or liver trouble ............ | ||||
| Blood Problems ................................................. | Herpes or other STD .................................... | ||||
| Easy bruising ................................................... | HIV-positive / AIDS .................................... | ||||
| Frequent nose bleeds...................................... | Glaucoma ....................................................... | ||||
| Abnormal bleeding.......................................... | History of head injury ................................. | ||||
| Blood disease (anemia) .................................. | Epilepsy or other neurological disease .... | ||||
| Ever require a blood transfusion?................. | History of alcohol or drug abuse .............. | ||||
| Allergies .............................................................. | Please describe any disease, condition, or problem | ||||
| Hay fever ......................................................... | not listed above that you feel we should know | ||||
| Sinus problems ............................................... | ___________________________________ | ||||
| Skin rashes ...................................................... | |||||
| Taking allergy medication ............................ | Are you allergic to any medications or anesthetic? |
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| Asthma ........................................................... | (ie. antibiotics, "novocaine", sulfa drugs, aspirin) | ||||
| Intestinal Problems .......................................... | If so, what? ___________________________ | ||||
| Ulcers ............................................................. | ____________________________________ | ||||
| Weight gain or loss ..................................... | What medications are you currently taking? | ||||
| Special diet ................................................... | ____________________________________ | ||||
| Constipation/Diarrhea ................................ | ____________________________________ | ||||
| Kidney or bladder problems ...................... | What other medications have you taken in | ||||
| Bone or Joint Problems ................................. | the past 12 months? _____________________ | ||||
| Arthritis ........................................................ | _____________________________________ | ||||
| Back or neck pain ....................................... | Women | ||||
| Joint replacement or surgery .................... | Do you take contraceptives or other hormones? | ||||
| Fainting spells, seizures, or epilepsy ........... | Are you pregnant? | ||||
| Frequent or severe headaches ..................... | Are you nursing? | ||||
| Thyroid problems .......................................... | Have you reached menopause? | ||||
To my knowledge, the above information about
myself is accurate and complete (signature):_________________________
date:_________