Dean Ramus Patient Update

ANNUAL PATIENT UPDATE
FULL NAME	NICKNAME	D.O.B.

CONTACT INFORMATION
PHONE (BEST CONTACT)	EMAIL ADDRESS
ADDRESS	CITY, STATE	ZIP
Is it okay to send appointment reminders with sensitive information to your email and cell phone?.................... Y N

MEDICAL HISTORY(check all that apply)
1. How is your general health? Excellent Good Fair Poor
2. Have you seen your primary medical doctor in the last 12 months?.................................................................................................................................................................................
3. Have there been changes in your medical condition in the last 12 months?................................................................................................................................................................ If so, please explain:
4. Have you had surgery or been hospitalized in the last 12 months? .................................................................................................................................................................................... If so, please explain:
5. Have you been instructed to take antibiotics before a dental appointment? ............................................................................................................................................................. If so, please provide the following information: Physician’s Name: Specialty: Phone: Condition Requiring Antibiotics: Antibiotic and Dose Prescribed:

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (e.g. Botox, collagen injections)

LIST ALL MEDICATIONS, SUPPLEMENTS, AND OR VITAMINS TAKEN WITHIN THE LAST 2 YEARS
Drug Purpose Drug Purpose

DENTAL HISTORY(optional, check all that apply)
BITE AND JAW JOINT
6. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)......................................................................................................................................................
7. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?...............................................................................................................................
8. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?.................................................................................................. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?.................................................................................................................................
9. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?....................................................................................................................................
10. Are your teeth becoming more crooked, crowded, or overlapped?........................................................................................................................................................................................
11. Are your teeth developing spaces or becoming more loose?...............................................................................................................................................................................................
12. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?..................................................................... Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?..........................................................................................................
13. Do you place your tongue between your teeth or close your teeth against your tongue?........................................................................................................................................
14. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?............................................................................................................................................
15. Do you clench or grind your teeth together in the daytime or make them sore?...............................................................................................................................................................
16. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or awareness of your teeth?..................................................................... Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or awareness of your teeth?..........................................................................................................
17. Do you wear or have you ever worn a bite appliance?.................................................................................................................................................................................................................................................................
SMILE CHARACTERISTICS
18. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size)?.................................................................. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size)?.............................................................................................................
19. Have you ever whitened (bleached) your teeth?........................................................................................................................................................................................................................................................
20. Have you felt uncomfortable or self-conscious about the appearance of your teeth?................................................................................................................................................................
21. Have you been disappointed with the appearance of previous dental work?....................................................................................................................................................................

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician.

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Reservation Policy: Each appointment is a reservation with one of our Doctors or Hygienists and we strive to be punctual because we value our patients’ time. We ask for a minimum of 48 hours notice to cancel or reschedule any reservations and to avoid a Missed Reservation Fee. For appointments over 2 hours long or scheduled outside of our normal business hours, we request a 25% non-refundable deposit to secure your reservation.

PATIENT’S SIGNATURE

DATE