Ethan Janson DDS - Family & Cosmetic Dentistry / Downtown Seattle / (206)623-0809
Patient Information
Simply print out these pages and bring them to your next appointment. Thank you
| Patient name:_____________________________ | |
| 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 previous 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 or discomfort? | |||||
| 10. Do your gums bleed when you floss? | 25. Do you have a temperomandibular (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 or around 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 |
||||||
| 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? | |||||
| 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 the past | |||||
| Bone or Joint Problems ................................. | 12 months? ___________________________ | |||||
| Arthritis ........................................................ | ____________________________________ | |||||
| Back or neck pain ....................................... | Women | |||||
| Joint replacement or surgery .................... | Are you taking contracetives 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:__________