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 Country
Home Phone*
Mobile Phone/Business Phone
Email 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 Contact
Emergency Contact*
First Last
Relationship
Parent Name (if minor)
Phone
Health History: Dental Information
Do 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 Information
Are 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
Allergies
Are 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
Medications
Please 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
Phone
This field is for validation purposes and should be left unchanged.

Hours of Operation
M-Th 8-4pm
Friday 8-2pm
Closed Saturday and Sunday

By Design Dental Patient Information Form

Emergency Contact

Health History: Dental Information

Health History: Medical Information

Allergies

Medications