David M. Kramer DDS, 530 Perinton Hills Office Park, Fairport, NY 14450, phone: 585.223.1980

david m. kramer, dds
530 perinton hills office park
fairport, ny 14450
585.223.1980

patient information

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	Full Name:		DOB (MM/DD/YYYY):
	Height:	Weight: lbs.	Sex: Male Female	SS#:
	Address:
	City:		State:	Zip Code:
	Home Phone:	Cell Phone:
	Emergency Contact:		Phone:	Relationship to you:
	Occupation:		Work Phone:

dental information

For the following questions, check whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.


	Do your gums bleed when you brush?		Yes No Don't know
	Have you ever had orthodontic (braces) treatment?		Yes No Don't know
	Are your teeth sensitive to cold, hot, sweets or pressure?		Yes No Don't know
	Do you have earaches or neck pains?		Yes No Don't know
	Have you had any periodontal (gum) treatments?		Yes No Don't know
	Do you wear removable dental appliances?		Yes No Don't know
	Have you had a serious/difficult problem associated with any previous dental treatment?		Yes No Don't know
	If yes, explain:
	How would you describe your current dental problem?
	Date of your last dental exam:
	Date of last dental x-rays:
	What was done at that time?
	How do you feel about the appearance of your teeth?

medical information

Have you had any of the following diseases or problems?

	Active Tuberculosis		Yes No Don't know
	Persistent cough greater than a 3 week duration		Yes No Don't know
	Cough that produces blood		Yes No Don't know
	Are you in good health?		Yes No Don't know
	Has there been any change in your general health within the past year?		Yes No Don't know
	Are you now under the care of a physician?		Yes No Don't know
	If yes, what is/are the condition(s) being treated?
	Date of last physical examination:
	Physician Name:
	Physician Phone:
	Physician Address:
	Have you had any serious illness, operation, or been hospitalized in the past 5 years?		Yes No Don't know
	If yes, what was the illness or problem?
	Are you taking or have you recently taken any medicine(s) including non-prescription medicine?		Yes No Don't know
	If yes, what prescribed medicine(s) are you taking?
	What over the counter medicine(s) are you taking?
	What vitamins, natural or herbal preparations and/or diet supplements are you taking?
	Are you taking, or have you taken any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or phen-fen (fenfluramine-phentermine combination)?		Yes No Don't know
	Do you drink alcoholic beverages?		Yes No Don't know
	If yes, how much alcohol did you drink in the last 24 hours?
	In the past week?
	Are you alcohol and/or drug dependent?		Yes No Don't know
	If yes, have you received treatment?		Yes No Don't know
	Do you use drugs or other substances for recreational purposes?		Yes No Don't know
	If yes, please list:
	Frequency of use (daily, weekly, etc.)
	Number of years of recreational drug use:
	Do you use tobacco (smoking, snuff, chew)?		Yes No Don't know
	If yes, are you interested in stopping?		Yes No Don't know
	Do you wear contact lenses?		Yes No Don't know

	allergies
	Are you allergic or have you had a reaction to:
	Local anesthetics		Yes No Don't know
	Aspirin		Yes No Don't know
	Penicillin or other antibiotics		Yes No Don't know
	Barbituates, sedatives, or sleeping pills		Yes No Don't know
	Sulfa drugs		Yes No Don't know
	Codeine or other narcotics		Yes No Don't know
	Latex		Yes No Don't know
	Iodine		Yes No Don't know
	Hay fever/seasonal		Yes No Don't know
	Animals		Yes No Don't know
	Food		Yes No Don't know
	If food allergy, please specify:
	Other		Yes No Don't know
	If other allergy, please specify:
	Metals		Yes No Don't know
	If metals allergy, please specify:
	To yes responses, specify type of reaction.

	Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?		Yes No Don't know
	If yes, when was this operation done?
	Have you had any complications or difficulties with your prosthetic joint?		Yes No Don't know
	If yes, explain.
	Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?		Yes No Don't know
	If yes, what antibiotic and dose?
	Physician or Dentist Name
	Physician phone

	women only
	Are you or could you be pregnant?		Yes No Don't know
	Are you nursing?		Yes No Don't know
	Are you taking birth control pills or hormonal replacement?		Yes No Don't know

diseases or problems

Have you had any of the following diseases or problems?

	Abnormal bleeding		Yes No Don't know
	AIDS or HIV infection		Yes No Don't know
	Anemia		Yes No Don't know
	Arthritis		Yes No Don't know
	Rheumatoid arthritis		Yes No Don't know
	Asthma		Yes No Don't know
	Blood transfusion		Yes No Don't know	If yes, date:
	Cancer / Chemotherapy / Radiation Treatment		Yes No Don't know
	Cardiovascular disease If yes, specify below:		Yes No Don't know
	Angina		Yes No Don't know
	Arteriosclerosis		Yes No Don't know
	Artificial heart valves		Yes No Don't know
	Congenital heart defects		Yes No Don't know
	Congestive heart failure		Yes No Don't know
	Coronary artery disease		Yes No Don't know
	Damaged heart valves		Yes No Don't know
	Heart attack		Yes No Don't know
	Heart murmur		Yes No Don't know
	High blood pressure		Yes No Don't know
	Low blood pressure		Yes No Don't know
	Mitral valve prolapse		Yes No Don't know
	Pacemaker		Yes No Don't know
	Rheumatic heart disease/Rheumatic fever		Yes No Don't know
	Chest pain upon exertion		Yes No Don't know
	Chronic pain		Yes No Don't know
	Disease, drug, or radiation-induced immunosuppression		Yes No Don't know
	Diabetes		Yes No Don't know
	If yes, specify		Type 1 Type 2
	Dry Mouth		Yes No Don't know
	Eating disorder		Yes No Don't know
	If yes, specify:
	Epilepsy		Yes No Don't know
	Fainting spells or seizures		Yes No Don't know
	Gastrointestinal disease		Yes No Don't know
	G.E. Reflux / persistent heartburn		Yes No Don't know
	Glaucoma		Yes No Don't know
	Hemophilia		Yes No Don't know
	Hepatitis, jaundice or liver disease		Yes No Don't know
	Recurrent Infections		Yes No Don't know
	If yes, Indicate type of infection:
	Kidney problems		Yes No Don't know
	Mental health disorders		Yes No Don't know
	If yes, specify:
	Malnutrition		Yes No Don't know
	Night sweats		Yes No Don't know
	Neurological disorders		Yes No Don't know
	If yes, specify:
	Osteoporosis		Yes No Don't know
	Persistent swollen glands in neck		Yes No Don't know
	Respiratory problems		Yes No Don't know
	If yes, specify:
	Emphysema		Yes No Don't know
	Bronchitis, etc.		Yes No Don't know
	Severe headaches/migraines		Yes No Don't know
	Severe or rapid weight loss		Yes No Don't know
	Sexually transmitted disease		Yes No Don't know
	Sinus trouble		Yes No Don't know
	Sleep disorder		Yes No Don't know
	Sores or ulcers in the mouth		Yes No Don't know
	Stroke		Yes No Don't know
	Systemic lupus erythematosus		Yes No Don't know
	Tuberculosis		Yes No Don't know
	Thyroid problems		Yes No Don't know
	Ulcers		Yes No Don't know
Excessive urination		Yes No Don't know
Do you have any disease, condition, or problem Not listed above that you think I should know about?		Yes No Don't know
Please explain:
Submit:

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or don not take because or errors or omissions that I may have made in the completion of this form.

medical history

patient information

dental information

medical information

allergies

women only

diseases or problems