DENTAL INTAKE QUESTIONNAIRE .o o

DENTAL INTAKE QUESTIONNAIRE
Directions To Patients:
Answers to these questions will help the dentist decide how to best
treat your dental problem. Please try to answer each question to
the best of your knowledge.
Medical and Social History
1. List all the medications or drugs you are presently taking.
Medications
Reasons
PATIENT LABEL AREA
lnstrucciones A Los Pacientes:
Respondiendo a estas preguntas ayudara en la decision para el
mejor tratamiento a su problema dental. Trate de contestar
cada pregunta.
Historia Medica Y Social
1. Anote las medicinas 6 drogas que esta tomando.
Medicinas
Razon
_______________________ _______________________
_______________________ _______________________
2. ('.Padece o ha padecido de alguna de las siguientes
2. Do you have or have you had any of the following
enfermedades? (Si si, ./)
o Presi6n arterial alta 6 baja
diseases or complications? (If yes,./)
o Heart Infections
o Infecciones de! corazon
o High or low blood pressure
o Derrame cerebral
o Heart Murmur
o Stroke
o Soplo en el coraz6n
o Hepatitis
o Rheumatic Fever
o Hepatitis
o Fiebre Reumatica
o HIV + I VIH
o HIV+
o Endocarditis
o Endocarditis
o Diabetis
o Heart Attack/Coronary
o Diabetes
o Ataque al coraz6n/coronaria o Tuberculosis
o Heart Surgery
o Tuberculosis
o_Epilepsia 6 convulsiones
o Operaciones de! coraz6n
o Angina
o Epilepsy (Seizures)
o Radilla o articulaci6n de
o Angina pectoral
o Knee or hip joint replacement
o Hemophilia
· cadera reemplazo
o Hemofilia
o Asthma
o Glaucoma
o Glaucoma
OAsma
Yes I No
3. Have you been treated by a physician or been in the hospital
3. ('.Ha sido tratado por un medico 6 ha estado en el
in the past year? ......................................... ."........ .. . . . .. ..... . . o ..... o
hospital el afi.o pasado? ...............................................CJ.•.•• o
o ..... o
4. Are you now pregnant or think you are pregnant?.....
4.
('.Esta
o piensa que puede estar embarazada? ...............CJ •••• o
Date expecting:-----------de espera: _____________�
Fecha
5. Are you now taking birth control pills?... .................... o ..... o
5.
('.Esta
tomando
pastillas para el control de la natalidadU .... o
6. Have you been treated for some allergic condition?...
o ..... o
6.
('.Ha
sido
tratado
por condiciones alergicas?................. .o ... o
7. Are you allergic to penicillin?.......................................... o..... o
7. ('.Es alergico a Ia penicilina? ......................................... JJ •.•. o
8. Has anyone ever told you not to take a particular drug
o ..... o 8. ('.Lehan dicho alguna vez que no tome alguna
(aspirin, novacaine, sulfa, etc.)?.......................................
medicina? (aspirina, novocaina, sulfa, etc.) ..................CJ .•. o
9. Are there any medications that make you sick or ill?... o ..... o
10. Do you take medication for nerve or emotional. problems?
9. ('.Ha tornado alguna medicina que lo haga sentir ma!? ..CJ ••• o
................................................................................................ .0 ..... 0 10. lEsta tomando medicinas para los nervios o problemas
1 I. Have you ever had prolonged bleeding (more than is
emocionales? .............................................................. JJ •••. CJ
normal for you) from a cut, injury, or tooth extraction?.
o .....o 11. lHa sangrado mas de Io normal por unaherida o
12. Have you ever had anemia, low blood or thin blood?... o ..... o extracci6n
dental?
13. Have you ever had other serious or disabling problems
0 .... 0
.............................................................. .. ...............
with your blood, spleen or lymph nodes?......................... o ..... o 12. lHa padecido de anemia? ......................................... .C:l••.. o
o ..... o 13. lHa padecido algun problema serio de la sangre, bazo
14. Do you smoke or drink? How Often?:
15. Have you ever had blackout or fainting spells (suddenly
o glandulas Iinfacticas? ............................................. 0.... 0
o..... o
lost track of things for a few minutes)?............................
14. lFuma o bebe? ('.Cuanto?:
.....................0 .... 0
16. Have you taken daily cortisone medication{Prednisone) in
15:
lHa
padecido
de
desmayos
(
de
pronto
ha
perdido la nocion
o ..... o
the past year? ...................................................................
de
las
cosas
por
unos
minutes)?
....................
.............. J:l ... o
o..... o
I 7. Have you ever had stomach or duodenal ulcers?........
16.
lHa
tornado
medicina
de
cortisona
diariamente?
....... JJ ... o
18. Have you ever had pain in your jaw joint..................... o ..... o
17.
lHa
padecido
de
ulceras
de!
estomago
o
duodenale?
.. o .... o
I 9. Do you have any serious or disabling problems with your
18.
lHa
padecido
de
dolores
en
las
coyuntras
de
Ia
quijado
o
............
o
.....
o
bones,joints or muscles?.....................................
mandibula? ................................................................ JJ .... o
20. Have you had surgery or x-ray treatment for a tumor,
o ..... o 19. lTiene algun problema serio o incapacitante con sus
growth or other condition of your mouth or lips?......
huesos, coyunturas o musculos? ................................. 0 ... o
21. Any other medical problems? ........................................ o ..... o
20. lHa tenido alguna operacion o tratamiento de rayos-x
• · por un·tumor u otra condicion de la boca o labios? .....CJ ••• o
21.lPadece usted de algun significante problema medico'tl .... o
Pae 2
DENTAL HISTORY
1. Why do you want to see a dentist?
YesjNo
HISTORIA DENTAL
1. 6Por que quiere ver un dentista? --------
Sil No
2. Have you ever been to a dentist before? ...................... o ..... o 2. 6Ha estado anterionnente en el dentista? ....................... o ..... o
If yes, about when was the last time?
6Cuando? 6Por que razon? ___________
-3, lLe ban-tornado, una serie completa de rayos-x de los
For what reason?
dientes? .............................................................................. o .....o
3. Have you ever had a complete series ofx-rays taken of your
teeth?..................................................................................0 ..... 0 lSi si, cuando fue la ultima?O 1 aflo O 2 aflos O 3 ai'ios o mas
If yes, when was the last: 0 I year O 2 years O 3 yrs or more 4. lCuantas veces al dia se lava los dientes? _____
4. · How many times a day do you brush your teeth?_
5. lLe ha ensei'iado algun (dentista, higienista, enfermera o
5. Has anyone (dentist, hygienist, nurse or physician) ever
medico) como limpiarse los dientes? ................................ o ..... o
shown you how to clean your teeth?..............................
o ..... o 6. lUsa hilo dental regularmente? ....................................... o ..... o
6. Do you use dental floss regularly?................................. D ..... o 7. lHa tenido alguna vez tratamiento para las encias? ..... o ..... o
7. Have you ever had treatment for your gums?............... o ..... o 8. lCuando se cepilla los dientes le duelen o sangran las
........... ,., .......................................... o ..... o
8. Do your gums bleed or hurt when you brush them?.,._.. o., ..,q .. e.ncias? .,.,.
1,,....... ,
9. Do your teeth feel loose? ................................................ .0 ..... 0 9. lSe siente sus dientes flojos? .......................................... o ..... o
10. Are you sensitive to heat, cold, or sweets?................. o ..... o 10. lSon sus dientes sensitivos a lo caliente, lo frio, o lo dulce?
11. Do any teeth hurt when you chew?............................... o ..... o ............................................................................................... 0 ..... 0
11. 6Cuando mastica, le duele algun diente o muela? ....... o ..... o
12. Do you clamp, clench, or grind your teeth during the day or
night? ................................................................................ .0 ..... 0 12. lFija, aprieta, o masculla usted los dientes durante el dia o
13. Have you been aware of any swelling in the face or neck?
la noche? ............................................................................ o ..... o
.......................................................................................... Q..... O 13. lSe la ha hinchado SU cara O cue!lo? ............................. 0 ..... 0
14. Do you have other serious or disabling tooth, gum, or jaw
14. 6Tiene algun otro problema serio con sus dientes, encias o
problems?..........................................................................i::i ..... o mandibula? ...................................................................... o ..... o
1
15. Para los padres:
15. For Parents:
Does your child suck his thumb?................................... 0 .....0
6Se chupa su hijo el dedo? ................................................0 ..... 0
Does your child go to sleep with the bottle in his/her
6Se duerme su hijo con la botella de leche en la boca?.. o ..... o
mouth? ............................................................................ .Q ..... o
He contestado lo mejor y lo mas correcto posible las
To the best of my knowledge, the foregoing medical and
preguntas anteriores.
dental questions have been accurately answered.
0,;,.,,••
(Si menor, padre o guardian)
(If a minor, parent or guardian must sign)
Dentist's Signature: _______________
Dentist's Signature: ---------------
REVIEW OF HEALTH HISTORY AND
MEDICAL RECORD
(Update at each recall)
EXAMINING DENTIST'S SUMMARY OF SIGNIFICANT MEDICAL FINDINGS:
Date
Medical Referral To:
Dental Precautions:
155 Bay Street Staten Island, NY 10301
Telephone: 718.876.8100 Fax: 718.876.8100
www.baydentalatthepointe.com
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