Fillable TMJ New Patient Form

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TMJ New Patient Form

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  • 31 check-boxes
  • 525 other fields

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Patient InformationTMJ
Last Name First Name Middle Name
Pronunciation:
I prefer to be called: Birth Date:
Residence Address:
City: State: Zip Code:
Residence Phone: Cell Phone: Fax:
Email ID:
If less than one year, previous address:
City: State: Zip Code:
Social Security Number: Driver's License No.
Occupation: Employer:
Employer Address: City:
State: Zip Code: Work Phone:
Patient Details
Spouse Details
Marital Status:
Name of Spouse:
Last First Middle
Spouse SS#
Spouse's Occupation: Employer:
Employer Address: City:
State: Zip Code: Work Phone:
Relative's Details
Name of nearest relative not living with you: Address:
City: State: Zip Code: Work Phone:
Last Name First Name Middle Name
Who is legally responsible, if other than the patient?
Relationship to patient:
Address: City:
State: Zip Code: Work Phone:
How did you find out about the Dental Wellness Center?
Robert P. McBride, D.D.S., M.A.G.D
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Insurance benefits vary considerably from contract to contract. In spite of our efforts, we find it impossible to be sure what
you will get back ... it's very frustrating.
Although we are not contracted with any dental insurance companies, for those of you that have dental insurance that
allows freedom of choice of dentists, we fully commit to obtaining any and all benefits that lie within your contract. If you
would be interested in learning why we are not contracted with 3rd parties, go to our website,
www.LongBeachHolisticDentist.com, click the "Resources" tab, go to articles, and scroll down to the "Dental Insurance
Misnomer" article.
The financial obligation for dental treatment is between you and our office - your insurance company is responsible to you,
and not to our office. We will assist you in any way that we can.
To expedite your receiving all benefits due you, please fill out the following:
Name of Insured :
Birth date: Social Security Number:
Employer Name:
Insurance company (Carrier) name:
Name of Group Plan: Group number:
Address of insurance company:
City: State: Zip Code:
Phone number of insurance company:
If you have secondary dental insurance:
Name of other insured party:
Date of Birth of other insured party:Social Security Number:
Employer Name:
Insurance company (Carrier) name:
Name of Group Plan: Group number:
Address of insurance company:
City: State: Zip Code:
Phone number of insurance company:
Dental Insurance
Robert P. McBride, D.D.S., M.A.G.D
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Client: Date:
Dental treatment is an excellent investment in an individual's physical and psychological well being. Financial
considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that different
people have different needs in fulfilling their financial obligations, we are providing the following payment options.
PAYMENT OPTIONS:
Two Payments (for treatment over $1,000 that have more than one visit)
Total patient obligation may be divided as follows: 50% due at the first treatment visit, with the remaining balance paid at
last visit. For any fees under $1,000, the full amount is due at the initiation of any procedure.
Treatments today ... Payments tomorrow ...
We are pleased to offer Care Credit. It is convenient, no initial payment, low monthly payment plan for dental treatments of
$200 to $25,000. Offering Care Credit allows us to make the smile you’ve always wanted affordable.
Apply from home:
Care Credit: 1-800-365-8295
Apply online 24 hours, 7 days a week:
Care Credit: www.carecredit.com
Pay as You Go. You may choose to pay your entire obligation for each visit, at the visit.
FORMS of PAYMENT and BALANCES DUE
In order to facilitate access to the very best health care possible, you may choose from any of the following (including any
combination thereof): Cash, Visa, MasterCard, American Express, Discover, Money Order, Personal Checks or Care
Credit (see above).
I have read and understand all the above
Patient Signature
Financial Menu
Robert P. McBride, D.D.S., M.A.G.D
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Alcohol: # drinks daily
Anemia
Angina
Ankle Swelling
Artificial Heart Valve
Artificial Joints, Plates, Screws
Asthma
Atherosclerosis
Auto Immune Condition
Blood Disease
Bruise Easily
Cancer
Chemotherapy
Congenital Heart Lesions
Diabetes/Prediabetes
Dizziness/Fainting
Drug Addiction
Emphysema
Excessive Bleeding
Fainting
Glaucoma
Heart Conditions
Heart Lesions
Heart Murmur
Heart Surgery
Hepatitis: A B C
High Blood Pressure
HIV Positive/AIDS
Jaundice
Kidney Disease
Liver Disease
Fatigue Easily
Hypoglycemia
Leukemia
Low Blood Pressure
Mitral Valve Prolapse
Nervousness /Depression
Pacemaker
Periodontal Disease
Radiation (Head / Neck)
Prophylactic antibiotics
before cleaning or dental
treatment
Recreational Drugs, such
as marijuana, stimulants,
depressants that may have a
fatal with local anesthetics or
other common dental
medications?
Respiratory Problems
Rheumatoid Arthritis
Rheumatic Fever
Osteoarthritis
Birth Control
Nursing
Pregnant: Delivery Date
Women Only
Scarlet Fever
Seizures
Sinus Problems
Smoker
Snore or gasp for air during sleep
Sleep Apnea
Stomach Problems
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
Are currently being treated for any of the above conditions? Yes
If being treated for another condition, please describe:
No
Have you gained or lost weight within the last year? If so, How much?
Current Weight:
Which one(s)?
Current Height:
Please check areas that apply to you
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Robert P. McBride, D.D.S., M.A.G.D
Medical Health History
Family Physician: Date of last visit:
Specialty: Date of last complete physical:
Address: City:
State: Zip Code: Phone # with Area Code:
Additional Physician: Date of last visit:
Specialty:
Address: City:
State: Zip Code: Phone # with Area Code:
Additional Physician or Health Provider, such as Chiropractor, Naturopath, Homeopath, Acupuncturist, etc.
Date of last visit:
Address: City:
State: Zip Code: Phone # with Area Code:
Date of last visit:
Address: City:
State: Zip Code: Phone # with Area Code:
Date of last visit:
Address: City:
State: Zip Code: Phone # with Area Code:
Provider Information
Fosamax
Aredia
Didronel
Actonel
Zometa
Skelid
Boniva
Biphosphonates
Phen Fen
Please check if you have ever taken any of the following drugs
Please name the pharmacy you use:
City: Phone:
Are you taking vitamins; food supplements; herbal preparations? Please list.
Please list ALL medications you currently take. (Prescription & Over The Counter. Attach List if Needed)
Please feel free to offer any dental or medical information below that would assist us in getting to know you better
No chance of dozing = 0 Slight chance of dozing = 1 Moderate chance of dozing = 2 High chance of dozing = 3
Sitting and Reading
Watching TV
Sitting inactive in a public place, ie... theater or a meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon if conditions permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL SCORE
Sleep Disordered Breathing is highly prevalent in the U.S. population. This brief survey has been quite useful in
discovering whether this possibility exists.
Using The Epworth Sleepiness Scale of 0 – 3 How likely are you to doze off or fall asleep in the following situations?
Aspirin
Codeine
Darvon
Erythromycin
Latex
Anesthetic
Nitrous Oxide
Sulfa
Percodan
Penicillin
Antibiotics
Other Allergies
Please list other allergies.
Please check if you have any of the following drug allergies?
Is there a disease or condition not listed above that you think I should know of?
Yes No If Yes, what?
I certify the information recorded on this medical & dental form is correct. I understand it is my responsibility to notify The Dental Wellness Center of any
changes. I understand that if I withhold information regarding allergies, medical conditions, medications, or supplements, I agree not to hold The Dental
Wellness Center or its employees liable in the event of death or injury. Authorization is given for dental treatment to be rendered by the dentist and office
staff, and I will assume financial responsibility.
Signature (Patient / Guardian) Date Dentist Signature
Oral Malodor (Bad Breath)
Bad Taste
Dissatisfied With Appearance of My Teeth
Teeth Clenching Teeth Grinding
Uncomfortable Bite Uneven Bite
Changing Bite
Jaw Joint (TMJ) Pain/Soreness/Discomfort Jaw Joint
(TMJ) Noise (Popping/Clicking)
Ringing in The Ears (tinnitus)
Difficulty in Opening Mouth Difficulty in Chewing
Headaches/Migraines
Pain or Soreness Around Eyes Ears
Vertigo, Dizziness or Balance Problems
Facial Head
Neck Shoulder
Pain Stiffness
Unusual Reaction to Dental Anesthesia ("Shots") Jaw
Surgery
Root Canals
Sleep Apnea
CPAP Machine or Sleep Appliance
Night Guard
Fear or anxiety level regarding dental treatment
e o n y v e d nt tr tm
Sensitivity to:
Pressure from biting or chewing
Hot Cold Sweet
Chipped/Broken Teeth
Teeth wearing away abnormally
Crooked or Tipped Teeth
Loose Teeth
Missing Teeth
Gaps/Food Traps between teeth
Dry Mouth or Constantly Thirsty
Burning Sensation in Mouth/Tongue
Smoke or Use Chewing Tobacco
Growths or Swellings in Mouth
Bleeding, Swollen or Irritated Gums
Grooves or Recession at Gumline
Allergic to Dental Materials
Specialty Dentist: Period of Treatment :
Address:
City: State: Zip:
E-mail: Phone:
Your answers to this dental history questionnaire will help us to understand your specific dental problems, so that we may more
effectively treat you with consideration of your individual needs.
Date of last complete x-rays? / Date of last oral cancer screening / Date of last cleaning? /
What is the primary reason you selected the Dental Wellness Center?
Please check conditions that apply to you
Dentures or Removable Partial Dentures
Fixed Bridge
Braces or Clear Braces
Dental Implants
Crowns
Veneers
Any Serious Trouble With Past Dental Treatment
1 2 3 4 5 6 7 8 9 10
0
Please check all areas that apply to you
Dental Health History
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Robert P. McBride, D.D.S., M.A.G.D
How important is your dental health to you?
Where would you rate your current dental health?
1 2 3 4 5 6 7 8 9 10
On a scale of 1 - 10, with 10 being the highest rating:
Please check any condition that applies to your parents (Mother/Father)
Heart disease
Heart attack
High blood pressure
Stroke
Low blood pressure
Diabetes
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Cancer
Pre-term birth
Gum disease
Tooth loss
Dentures
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Family Medical/Dental History
Make My Teeth Whiter
Make My Teeth Straighter
Close Spaces or Gaps That Bother Me
Replace Dark Fillings With Tooth Colored Replacements
Fix My Teeth So I'm Not Embarrassed To Smile
Repair Chipped Teeth
Fix "Gummy" Smile
Replace Missing Teeth
Replace Old Crowns That Don't Fit Right or Match
Have A Smile Makeover
Stop My Jaw From Hurting or Clicking
Stop My Gums From Bleeding
If I could change my smile, I would:
TMJ Patient Information
Robert P. McBride, D.D.S., M.A.G.D
(562) 421-3747
www.LongBeachHolisticDentist.com
leanne@rpmdentistry.com
Dental Wellness Center
5406 E. Village Road
Long Beach , CA , 90808
Please answer all questions to the best of your ability - use additional paper if necessary.
Describe your problem1.
Do you have a clicking, popping or grating noise in your2.
Right Jaw Joint
Left Jaw Joint
Yes No
Yes No
When did you first notice the noise?3.
Right: Left:
Has the noise recently become more pronounced?4. Yes No
When?
Do you have pain in or around the right joint?5. Yes No
Yes NoDo you have pain in or around the left joint?
When did you first notice the pain?6.
Right: Left:
Is the pain worse:7.
Mornings:
Evenings:
At Meals:
No Specific Time:
Has the pain recently become more pronounced?8. Yes No
When?
Is the pain:9.
Dull, achy
Continuous Sharp, Stabbing
Intermittent Throbbing
If other, please describe:
Does the pain sometimes feel like it’s in your ear?10. Yes No
Do you think this problem has affected your hearing?11. Yes No
Do you hear a ringing noise (tinnitus)?12. Yes No
Constant
Intermittent
Do you have vertigo (periods of dizziness)?13. Yes No
Does your jaw problem interfere with your normal activities?14. Yes No
Do you have any idea what triggered the problem, what caused it, or what makes the problem continue?15. Yes No
Explain
Do you have frequent headaches or neckaches?16. Yes No
What Area(s)?
How Frequent?
Have you ever had a severe blow or trauma to the head, neck, or jaw?17. Yes No
Which area?
Explain:
Do you have difficulty chewing?18. Yes No
Because of Pain in Joint
Limited Opening Pain in Teeth
Missing Teeth Clicking
Other:
Has your mouth ever locked open so you were unable to close it?19. Yes No
Explain
Have you had problems opening your mouth wide?20. Yes No
Explain
Do you feel as if your teeth don’t have a “home base” to close to, or that your bite is changing?21. Yes No
Have you ever been told that you grind your teeth during sleep?22. Yes No
Please indicate the time sequence in which you became aware of the following problems list.
Number only those problems that apply to you.
23.
Yes No
Pain: Noise: Limited opening:
Locking: Other:
Which aspects of your problem concern you the most?24.
Explain
Are you aware of clenching your teeth?25. Yes No
Do you grind your teeth?26. Yes No
Has there been a recent change in your lifestyle such as a change in marital status, childbirth,
change of employment, death in the immediate family or other stressful events?
27.
Yes No
Explain
Do you have young children under your care?28. Yes No
Do you smoke a pipe?29. Yes No
Do you chew gum?
Yes No
Do you bite your nails?
Yes No
Do you have any other nervous habits?
Yes No
Describe any habits at work or home which might place your body in a strained or awkward posture
(such as holding a phone with a shoulder or carrying equipment.
30.
Do you think nervous tension seems to affect this problem?31. Yes No
Explain
Have you had problems with other joints?32. Yes No
Explain
Is there any history of similar problems in your family?33. Yes No
Have you had orthodontic treatment?34. Yes No
When? Where?
Have you had recent dental treatment?35. Yes No
If yes, when?
Where?
Describe your past dental treatment in general.36.
Have you ever had x-rays taken of your jaw joints?37. Yes No
When? Where?
List the names of all the health professionals you have seen for treatment of this problem, chronologically.38.
A.
B.
C.
D.
E.
F.
G.
H.
Discuss the relative success of your prior treatment(s).39.
List all medications you are (a) now taking, (b) have taken for this problem.40.
Signature: Date:
Please comment on your nutrition.41.
Do you use vitamins?42. Yes No
If yes, name and give dosage.
Do you smoke?43. Yes No
How much?
Comment on your sleep patterns: Such as – time you go to sleep, sleep positions, amount of sleep, etc.44.
Are you afraid your problem is serious?45. Yes No
Any ideas as to what should be done?46.
Your medical history:47.
Are you under current medical care?a. Yes No
If yes, for what?
Any major illness or operations?b. Yes No
What?
When?
Are you now taking any drugs or medications other than what you might have mentioned in question #40?c. Yes No
If yes, please note.
Do you have any adverse reactions to drugs?d. Yes No
If yes, please note.
Do you consider yourself in good health?e. Yes No
Please comment
Please add to the above information if you wish.48.
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TMJ New Patient Form

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Completed 7 January 2022

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