Drboch.com

Jason A Boch DMD LLC
Jason A. Boch, DMD DMSc
Diplomate of the American Board of Periodontology
Patient Name:__________________________________________________________________ Name of Parent (if patient is a minor):_______________________________________________ Home Address:_________________________________________________________________ Home phone #:_______________________ Work phone #:______________________________ Cell phone #:________________________ Email:____________________________________ Employer:__________________________ Occupation:________________________________ Social Security #: ___________________________ Subscriber name:__________________________ Subscriber date of birth:________________ Dental Insurance Company (Primary):_______________________________________________ Dental Insurance Company (Secondary):_____________________________________________ Subscriber name:__________________________ Subscriber date of birth:________________ What dental problem brings you to our office? ________________________________________ ______________________________________________________________________________ Who recommended you to our office? _______________________________________________ Who is your restorative/family dentist? ______________________________________________ Physician's name: __________________________ Phone number: _______________________ In case of emergency contact name/phone #: _________________________________________ Dental History
1. Do you clench or grind your teeth?___________Do you wear an appliance for this?_________ 2. Have you had any periodontal treatment or dental implants, please describe? _____________________________________________________________________________ 3. Are there any areas in your mouth that have food impaction? __________________________ 4. Are there any areas in your mouth where you do not like how the gingiva looks?___________ 5. Have you had orthodontic treatment? ______ When? _________ 6. How often do you brush your teeth? ___ each day. Do you use an electric or manual toothbrush _______________ Are the bristles soft/medium/hard? _______________. 7. How often do you floss? ____/week. List anything else you use to clean your teeth __________________________________________. Medical History
1. Please list all medications that you are taking including prescription, non-prescription, and herbal supplements: _____________________________________________________________ _____________________________________________________________________________________ 2. Please list any bisphosphonate medications you have taken in the past (such as Fosamax, Zometa, Actonel, Boniva, Aredia) for osteoporosis or cancer: ____________________________ How many years have you taken it?____ Did you ever have it administered intravenously?_____ 3. Do you have any allergies including drugs, foods, latex? ________ Please List ____________________________________________________________________ 4. Do you use tobacco products (smoking or smokeless) ______ For how many years? ______ Please List ________________________________________________ 5. Do you require antibiotic premedication before dental appointments (please list the reason for premedication and what you take)? _________________________________________________ 6. If you are female, are you pregnant, or is there a chance you are pregnant? ________________ 7. Do you drink alcohol? How much each day? _______________________________________ Please mark YES or NO and describe below:
1. Do you have any medical problems/illnesses? 3. Do you take any blood thinning medications such as aspirin, Coumadin, Plavix, aggrenox? Please list below. 4. Do you have any prosthetic joints, valves, or a heart murmur? 5. Do you have a history of sinus problems or sinus treatment? 6. Any history of cardiac problems, stroke, or high blood pressure 7. Is there any history of treatment for cancer? 8. Have you ever had radiation treatment? 9. Do you bruise or swell easily, or bleed for an excessively long time? 10. Do you have diabetes? How do your blood sugrars run? 12. Have you ever had any of the following: rheumatic fever, asthma, fainting/seizures, liver disease, HIV, gastrointestinal disease, kidney disease, tuberculosis, blood disorder? Please explain any items from above: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you have any other medical problems or conditions that the doctor should know about? ______________________________________________________________________________ ______________________________________________________________________________ __________________________________

Source: http://www.drboch.com/documents/WebsiteHealthHistory_001.pdf