& PHILIPPINE DENTAL ASSOCIATION (DENTAL CHART) PATIENT INFORMATION RECORD Name: Tast First Middle Birthdate(mmvddlyy) . (a ale Sex: M/F Religion: Nationality: Nickname Home Address: Home No. ‘Occupation: Office No. Dental Insurance: Sanaa Fax No.: Effective Date: For minors: Parent Guardian's Name: Occupation: Whom may we thank for referring you? What is your reason for dental consultaion? DENTAL HISTORY Previous Dentist: Dr. Last Dental visit: MEDICAL HISTORY Name of Physician: Dr. Office Address: 41. Are you in good health? 2. Are you under medical treatment now? __ Specialty, if applicable: Office Number: If's0, what is the condition being treated? 3, Have you ever had serious illness or surgical operation? 's0, what illness or operation? 4, Have you ever been hospitalized? I's, when and why? Iso, please specify Do you use tobacco products? (_) Sulfa drugs 9 Bleeding Time 40. For women only 5, Are you taking any prescription/non-prescription m Do you use alcohol, cocaine or other dangerous drugs? Are you allerg to any of the following (() Local Anesthetic (ex. Lidocaine) ( (Aspirin ) Penicilin , Antibiotics () Latex () Others ‘Are you pregnant? Ate you nursing? ‘Ate you taking birth control pills’? 11. Blood Type 12. Blood Pressure 18. Do you have or have you had any of the following? Check which apply (.) High Blood Pressure (_) Low Blood Pressure (.) Epilepsy / Convulsions ( )AIDS or HIV Infection ) Sexually Transmitted disease Stomach Troubles / Ulcers Fainting Seizure Rapid Weight Loss Radiation Therapy Joint Replacement / Implant Heart Surgery Heart Attack ( ( ( ( ( ( ( ( () Thyroid Problem ) ) ) ) ) ) ) ) (.) Heart Disease () Heart Murmur (_) Hepatitis / Liver Disease (.) Rheumatic Fever () Hay Fever / Allergies (_) Respiratory Probiems () Hepatitis / Jaundice ( ) Tuberculosis (.) Swollen ankles () Kidney disease ( ) Diabetes () Ghest pain () Stroke, Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No () Cancer / Tumors (Anemia () Angina () Asthma () Emphysema ( ) Bleeding Probiems (_) Blood Diseases () Head Injuries ( )Antritis / Rheumatism () Other SignatureTREATMENT TO BE DONE: understand and consent tohave any treatment done ty the dentist after the procedure, the risks & benefits & cost have been fully explained. These treatments include, but are not limited to, x-ays, cleanings, periodontaltreatments, filings. crowns, bridges, alltypes of extraction, root canals, &/or dentures local anesthetics & surgical cases. (initia ) DRUGS & MEDICATIONS; | understandthatantibiotis, analgesics other medications can cause llergic reactions like redness & swelting of issues, pain, itching, vomiting, 8/or anaphylactic shock (Initial: CHANGES INTREATMENT PLAN: understand that during treatmentit ay be necessary to change! add procedures because of conditions found hile working onthe taeththat was not discovered during examination For exampie, root cenal therapy may be needed followingroutine restorative procedures. give my permission to the dentist to make anylall changes and adcitions as necessary w/ my responsibility to pay allthe costs agreed. (initia: ) RADIOGRAPH:| understand that an -ray shotor a radiograph maybenecessary aspartof diagnostic ad to come up with tentative diagnosis of my Dental problem and tomake a good irealment plan, bul, thie willnot giveme a 100% assurance for theaécuracy ofthe treatment sincealldentaltr ‘re subject to unpredictable complications that later on may lead to sudden change of treatmentplan andsubject tonew charge (Initia: REMOVAL OF TEETH. tunderstandthataltematives to tooth removal (root canal therapy, crowns & periodontal surgery. etc) & Icompletely understand these alternatives including the risk & benefits prior to authorizing the dentisito remove teeth &any other structures necessary orreasors above. \understand that removing teeth doos notalways remove alltheinfections, if prosant, & itmay be necessary te have further treatment understand theriskinvolved inhaving teeth removed, such as pain, swelling, spreadof infection, dry socket, fractured jaw, loss of feeling onthe teeth ips,tongue & ‘surrounding isave that canlastfor an indefinite period of time. lunderstand that may needfurther Yeatmentundera specialist complications anise during or following treatment. (initia CROWNS (CAPS) & BRIDGES: Proparing a tooth mayirrtate the nervetissue inthe center of the tooth, leaving the tooth extra sensitive toheat, cold & pressure Treating suchirritation may involve using special toothpastes, mouth rinses or oot eanaltherapy. understand that sometimes tis not possible tomatch thecolorof naturaltocth exactly with artificial teeth. Hurther understand that mey be wearing temporary crowns, whiehimay come off easily &that! must be careful toensure that they are kept on until thepermanent crowns are delivered. tis my responsiblity to returnfor permanent ‘cementation within 20 days from tooth preparation, as excessive days delay may allow or tooth movement, which may necessitate aremake ofthe crown, bridge’ ap. | understand therewill be additional charges for remakes due tomy delaying of permanent cementation, &Irealize that final opporiunity to ‘make changes in my new crown, bridgesor cap (including shape, fit, size,& coir) will be belbre permanent cementation, (iti: ) ENDODONTICS (ROOT CANAL), uncerstand thereis ne guarantee that a root canaltreaiment willsavea tooth & that complications can occur trom thetreaiment & that occasionally root canal filingmaterials may extend through the tooth which does not necessarily effect the success of the treatment !understancthatendedontic files &drils areveryfine instruments & stresses vented inthe: manufacture & calcifications presentin eethcan cause them ‘to breakduring use. t understand that referral tothe endodontistfor additional treatments may be necessary following any root canaltreatment &1 agree that am responsible for any additional cost for treatment performed by the endodontist. understand thal a tooth may require removal in spite of allefforts tosavert, (Initial; PERIODONTAL DISEASE; l understand that periodontal disease is.a serious condition causinggum®& bone inflammation Borloss &thatcanlead ‘eventually othe loss of my teeth. understand the alternative treatment plansto correct periodontal disease, including gumsurgery toothextractions with or without replacement. understand that undertaking any dental procedures mayhave future adverse effect on my periodontal Conditions, (iti ) FILLINGS understand that care must be exercisedin chewing onrilings, especially during the first 24 hours to avoidbreskage. lunderstandthatamore extensive filing oF a crown may berequired, as additional decay or fracture may become evident after intial excavation. lunderstand that significant Sensitivity sa common, butusually temporary, after- effect of anewly placedfilling. further understand that filinga tooth may irritate thenerve tissue creating sensitivity & reating such senskivity could require root canal therapy or extractions. Onitit ) DENTURES: understand that wearing of dentures can be difficult Sore spots, altered speech & «iffioulty In eating are common problems. immediate dentures (placementof dentureimmediately after extractions) may be painful. Immediate dentures may require considerable adjusting & several reli |understandtnatitis my responsibilty toreturn for delivery of dentures. lunderstand that fallureto keep my delivery appointment may result inpoorly fitted dentures. fa remakels required due tomy dolays of morethan30 days, there will be additional charges, A permanent reline will be needled tat which isnotincluded inthe initial fee. lunderstand thatall adjusiment or alterations of any kind after this initial period issubjectto charges. (Inia understand that dentistry is not an exact science and that no dentist can properly guarantee accurate results all the time, "hereby authorize any of the doctors /dental auxiliaries to proceed with & perform the dental restorations & treatments as explained tome. l understand ‘thatthese are subject to modification depending on undiagnosable circumstances that may arise during the course of treatment. | undorstand thal regardless of anydental insurance coverage! may have, lam responsible for payment of dental fees, lagree topay any attorney'sfees, collection fee, or court costs that may be ncurredto satiety any obligation tothis office. All treatment were properly explained tome ary untoward circumstances Pat ‘may arise during the procedure, the attending dentist will not beheldliable since itis my free will, withfull trust & confidence in him/her, toundergo dental Treatmentunderhisiher care, Patient /Parent Guardian Signature Dentist /Signature DateINTRAORAL EXAMINATION Name: Gender :M/F Date: Age: status a Richt a ETH saad TEMPORARY es a ai status Legend: Condition Restorations & Prosthetics Surgery ¥ «Present Teeth D -Decayed (Caries Indicated for Filing) M - Missing due to Carios, ‘Am - Amaigam Filing Co-Compesite Filling JC- Jacket Crown X -Extraction due to Caries XO - Extracion due to Other Causes MO - Missing due to Other Causes ‘Ab - Abutment X-ray Taken: Im - Impacted Tooth Att Atlachment ___ Periapical (Tth No.:_) Sp - Supernumerary Tooth P -Pontic — Panoramic. Rf Root Fragment In- Inlay = Cephalometric Un- Unerupted Inmp = Implant = Octlusal (UpperiLower) 'S - Sealants __ Others: Rm - Removable Denture Periodontal Screening: Occlusion Appliances: TMD: Gingivitis Class (Molar) Orthodontic Clenching Early Periodontitis ___ Overjet Stayplate Clicking Moderate Periodontitis Overbite —_ Others Trismus ‘Advanced Periodontitis, Midline Deviation Muscle Spasm CrossbiteName: Age: Gender: MIF Tooth Amount | Amount Next Date | Nols Procedure Dentists | charged | Paid | 22!ance| appt. memi/10