Medical Review Forms Personal Information, Medical & Dental Review Forms All information collected is kept confidential Name (First, M, Last ): M F DOB (d/m/y) : Client Status: Adult Adult - with a S.D.M. (P.O.A.) Child Name of person responsible for account: Name of person responsible for account Address / Mailing: Phone # Email : IN CASE OF EMERGENCY CONTACT : NAME, PHONE # Dental Insurance: No Yes Please fill out the following information * Relationship to person claiming: Employee/Subscriber Plan Member’s InformationGroup Policy# Certificate/ Id # Insurance company name: Employer (retired) under plan: DOB: (d/m/y) Full Name: Medical & Dental HistoryName of Doctor: Phone Number: Date of last physical: Name of Dentist: Phone Number: Date of last visit: Have you been at the hospital in the past two years? No Yes If yes, Why? Have you ever had surgery? Yes No If yes, than what type? When? Have you ever been advised to take antibiotics before dental treatment? Yes No PLEASE ANSWER THE FOLLOWING QUESTIONSHave you ever had a heart valve repaired or do you have a heart valve replacement? Yes No Have you ever had Endocarditis? ( Infection/inflammation of the heart) Yes No Congenital Heart Disease? Yes No Joint replacement / artificial knee, hip(s) etc...? Yes No Do you have a heart pacemaker? Yes No Do you have Diabetes? Yes No Do you have Rheumatoid or Osteoarthritis? Yes No Are you undergoing any Chemotherapy or Radiation treatment? Yes No Do you or have you ever had a Blood Disorder? Yes No Medical Conditions: Tobacco: Do you use tobacco? Yes No Cigarettes Chew Pipe Cigars Drugs: Do you currently use recreational or street drugs? Yes No Have you ever had the following conditions? Check yes or no / can circle condition as needed Cancer Yes No If yes then what type? Are you in complete remission? High or Low blood pressure? Yes No Heart Surgery, Heart attack, Heart murmur? Yes No Chest pain, Angina? Yes No Any urinary tract, bladder, or kidney infections within the last year? Yes No Stroke? Yes No Fainting or Dizziness? Yes No Anemia / low iron? Yes No Asthma, Emphysema, C.O.P.D, Bronchitis or frequent cough? Yes No Head or Neck injuries? Yes No Women Only:Are you pregnant? No Yes Breast feeding? No Yes Taking Birth Control? No Yes Are you taking fertility treatments? No Yes Do you have any Allergies? Food, Drugs or Environmental If Yes.... Please list on line below Yes No List Allergies Do you have Liver problems or Hepatitis A , B, or C Yes No Do you have Thyroid problems? Overactive Hyperthyroidism ( or) Underactive Hypothyroidism Yes No Epilepsy or Seizures? Yes No Do you have any glandular, endocrine or hormonal disorders? i.e.: pancreatitis, grave’s disease, adrenal gland etc... Yes No Do you have Parkinson’s Disease? Yes No Do you have Multiple Sclerosis or ALS? Yes No Alzheimer’s Disease? Early Middle Late Alzheimer’s Disease? Yes No Dementia Lewy Body Vascular Mixed Dementia Yes No Other mental or physical diagnosis not listed above: (Including eye conditions/surgeries) No Yes * Please explain: Please List all medications that you are taking. Include all over the counter, prescriptions & vi tamins/herbals. Attachments Okay... Name of Drug Strength / Dosage Frequency Taken DENTAL HISTORYAre you experiencing any Dental Discomfort? No Yes If yes, explain: Are any of your teeth loose? No Yes How Often do you brush your teeth? Do your gums bleed when brushing or flossing? Yes No Have you ever had an up setting dental experience? No Yes Are you nervous about having dental care? No Yes Are your teeth sensitive to: Hot Cold Sweet biting pressure citrus or carbonation Are your teeth sensitive Yes No Have you ever had any teeth extractions? Yes No Do you have a burning sensation of your lips, tongue or other? Yes No Is your mouth dry? Yes No Are you aware of bad taste in mouth or bad breath? Yes No Do you floss your teeth? If yes: how often? Yes No Do you use any dental aids? i.e.: tooth picks, soft picks, interdental brushes, floss sticks, sulca brushes, etc..... Yes No Do you use mouth wash? Yes No Does food get caught between your teeth? If yes... where? NOTESDo you wear Dentures? Yes No If yes, are your dentures a complete or partial denture? Partial Complete Are you aware of “grinding or clenching your teeth”? Yes No Do you breathe through your mouth? Yes No Does your jaw click or pop? Yes No Do you have pain or difficultly opening or closing your mouth? Yes No Have you ever had periodontal / gum surgery? If yes: when? Yes No Have you ever had “b races ” / orthodontic treatment? Yes No Have you ever had any complications with dental surgery/ or procedures? Yes No If yes please explain: LONG TERM CARE FACILITIESPlease indicate by checking off the box if there has been a history of the following: Delirium Depression Behavioral changes Gait changes / mobility Anxiety / restlessness Agitation Sensory Impairment Wandering/exit seeking Refusal of Care Inability to verbally communicate Performing repetitious mannerisms Verbal or physical aggression Recent changes in: Weight Energy level Altered sleep pattern Other pain/discomfort:
