By Design Dental Patient Information Form How did you hear about By Design Dental Implant Center?* Are you completing this form for another person?* Yes No Your Name Relationship Patient's First Name* Patient's Last Name* Gender* Female Male Custom Please enter your custom gender Date Of Birth (MM/DD/YYYY)* SS# or Patient ID This form is secure. You can confidently supply your SS#, but if you prefer to leave this blank, we can collect this information in the office.Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Mobile Phone/Business PhoneEmail Address Occupation Employer Check the box if you have any of the following diseases or conditions:* Covid-19/Coronavirus Persistent cough greater than 3-week duration A fever above 100 Exposed to anyone with Covid-19/Coronavirus None If you indicate you have any of these diseases or conditions, please stop and consult the receptionist. If you are not presently in the office, please call (484) 231-1177.Emergency ContactEmergency Contact* First Last Relationship Parent Name (if minor) PhoneHealth History: Dental InformationDo your gums bleed when you brush or floss?* Yes No Are your teeth sensitive to cold, hot, sweets, or pressure?* Yes No Does food or floss catch between your teeth?* Yes No Is your mouth dry?* Yes No Have you had any periodontal (gum) treatments?* Yes No Have you had any orthodontic (braces) treatments?* Yes No Have you had any problems associated with previous dental treatment?* Yes No Is your home water supply fluoridated?* Yes No Do you drink bottled or filtered water?* Yes - every day Yes - weekly Yes - occasionally No Are you currently experiencing any dental pain or discomfort?* Yes No Do you have earaches or neck pain?* Yes No Do you have clicking, popping, or discomfort in the jaw?* Yes No Do you brux or grind your teeth?* Yes No Do you have sores or ulsers in your mouth?* Yes No Do you wear dentures or partials?* Yes No Do you participate in active recreational activities?* Yes No When was your last dental exam? MM slash DD slash YYYY Have you ever had a serious injury to your head or mouth?* Yes No Date of last dental X-rays? MM slash DD slash YYYY What is the reason for your visit today?* How do you feel about your smile?* Health History: Medical InformationAre you in good health?* Yes No Has there been any change in your health in the past year?* Yes No When was your last physical exam? MM slash DD slash YYYY Are you now under the care of a physician?* Yes No For what condition? Please provide your physician's full name and phone number Have you had any serious illness, operation, or hospitalization in the past 5 years?* Yes No AllergiesAre you allergic to or have you had a reaction to: Local Anesthetics Metals Aspirin Latex (rubber) Sulfa drugs Codeine or other narcotics Animals Food Penicillin or other antibiotics Iodine Barbituates, Sedatives or Sleeping pills Hay fever/seasonal Other None MedicationsPlease list all current medications including herbs/holistic remedies, aspirin, blood thinners, vitamins or over-the-counter medications, or enter "None."* Do you wear contact lenses?* Yes No Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?* Yes No If yes, what was the date? MM slash DD slash YYYY If yes, were there any complications?* Yes No Are you taking or scheduled to begin taking any of the medications alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease??* Yes No Since 2001, were you treated or are you presently scheduled to begin with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia, or skeletal complications resulting from Paget's disease, multiple myeloma, or metastatic cancer?* Yes No If yes, date treatment began: MM slash DD slash YYYY Do you use controlled substances (drugs)?* Yes No Do you use tobacco (smoking, snuff, chew, bidis)?* Yes No If yes, how interested are you in stopping? Very Somewhat Not interested Do you drink alcohol?* Yes No If yes, how much did you drink in the last 24 hours? If yes, how much did you drink in the last week? Do you have or have you ever had any of the following diseases or problems? Cardiovascular disease Angina Arteriosclerosis Congestive heart failure Damaged heart valves Heart attack Heart murmur Low blood pressure High blood pressure Other congenital heart defects Mitral valve prolapse Pacemaker Rheumatic fever Rheumatic heart disease Abnormal bleeding Anemia Blood transfusion Hemophilia AIDS/HIV positive Arthritis Autoimmune disease Systemic Lupus Erythematosus Asthma Bronchitis Emphysema Sinus trouble Tuberculosis Cancer/Chemotherapy/Radiation Chest pain upon exertion Chronic pain Diabetes Type I or II Eating disorder Malnutrition Gastrointestinal disease G.E. Reflux/Persistent heartburn Ulcers Thyroid problems Stroke Glaucoma Hepatitis, Jaundice, or Liver disease Epilepsy Fainting spells or Seizures Neurological disorder Sleep disorder Mental health disorder Recurrent infections Kidney problems Night sweats Osteoporosis Persistent swollen neck glands Severe headaches/migraines Sexually transmitted disease Excessive urination Other Please specify the neurological disorder* Please specify the mental health disorder* Please specify the recurrent infection type* Please specify the Other medical condition* Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?* Yes No Please provide the name and phone number of physician or dentist making recommendation Are you pregnant? Yes No Are you nursing? Yes No Are you taking birth control or hormonal replacement? Yes No NameThis field is for validation purposes and should be left unchanged.