Adajar Dental Services – Professional Dental Care by Dentist Dr. Cielo P. Adajar. The finest Dental Care in the Philippines. Dental and Oral Hygiene Care. We take care of your teeth. Dental Clinic located at Quezon City. We create your smile.

Patient Information Sheet

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. Yes, we hate forms too, but this information is important. If you have any questions or need assistance, please ask us and We will be happy to help. Thank you for your cooperation.

Dr. Adajar and Team

Fields with an asterisk (*) are required.

* Last Name

*First Name

Middle Initial

Nickname

Birth date

Home Phone

Mobile Phone

Address

Marital Status Minor Single Married Divorced Separated Widowed

* E-Mail Address

Referred By

How did you find us? Yahoo Google MSN Other

Responsible Party

Name of Person Responsible for this Account

Relationship to patient

Home Phone

Address

Driver's License

Birthdate

Employer Work Phone SSS#

For your convenience we offer the following methods of payment. Please Check the options you prefer. Payment in full at each appointment Cash Personal Checks Credit Cards I wish to discuss the office's payment policy

Dental Concerns

What can we do to make you feel more at home?

	Yes	No
Would you like to be reminded of your appointments?
Would you like Coffee Hot Tea Iced Tea Juice when you arrive?
Would you like a MP3 DVD Movie TV to watch or listen to during the treatment?
Will you need blankets to help with the temperature?
Will you need a pillow to support your neck?
Would you like sunglasses to wear during you appointment?
Anything we have not thought of?

What did you not like about your past dental appointments?

	Yes	No
Was the treatment uncomfortable?
Was the staff unfriendly?
Were the fees not reasonable?
Were the fees not explained before your appointments?
Anything we have not thought of?

What are you feeling about your :

Front Teeth	Yes	No
Are you happy with their color?
Are you happy with their length?
Are they crowded or crooked?
Is braces an option?
Are there any chipped?
Are you happy with their overall appearance?
Anything about them you would like to change?

Back Teeth	Yes	No
Are they sensitive to hot or cold foods?
Do they trap food when you eat?
Anything about them you would like to change?

Gums	Yes	No
Do they ever bleed?
Are you seeing a periodontist? Who?
Do you have bad breath?
Anything about them you would like to change?

Missing Teeth	Yes	No
Do you have any missing teeth?
Are you wearing a replacement?
Is your denture or partial comfortable?

Other cosmetic information:

	Yes	No
Is there anything about your smile that you do not like?
Are you interested in knowing the options available for a more beautiful smile?
Is your bite comfortable when chewing, biting?
Do you have frequent headaches?
Do you have any old fillings or dental treatment that you are unhappy with?

We understand that your are here for us to help you care for your teeth and gums. Medications you are taking and health problems you may have could make a difference in how we treat your dental problems. We hate filling out forms as much as you do, but this information is very important is very important. Thank you in advance for your cooperation.

Medical History	Yes	No
Are you in good health

Medications	Yes	No
Are you taking any medications
Are you allergic to anything Aspirin Penicillin Codeine Latex Other

Heart Problems	Yes	No
What is your normal blood pressure?
Heart Murmur
Stroke
Heart Attack
Pace Maker
Rheumatic Fever
Angina
Heart Valve
Do you take antibiotics for dental treatment?

*** Periodontal Disease and Dental Infections may increase the risk of Stroke and Coronary Heart Disease.

Bleeding	Yes	No
Do you bleed easily? (Aspirin can cause this)
Are you on Coumadin or other blood thinners?
Do you have Hepatitis?
Do you have Jaundice?

Diabetes	Yes	No
Do you have Diabetes? Type 1 Type 2 Latest HbA1 Score %

***Recent studies have shown a link between Diabetes and Periodontal Disease. It is important to your health that they both be under control. The warning signs of Diabetes are frequent trips to the bathroom, thirsty all the time, and always feeling hungry.

BREATHING / LUNGS Yes No

Sinus problems

Seasonal Allergies

Bronchitis

Asthma

Snoring (Ask your spouse!)

Is it hard to breath normally through your nose?

Were your tonsils removed?

Do you wake up tired?

PREGNANCY Yes No

Are you pregnant?

Are you taking birth control pills?

***Antibiotics can interfere with birth control pills by causing them not to work. Periodontal infections can increase the risk for low birth weights in newborns. This is very dangerous!

CANCER	Yes	No
Do you have cancer?
Have you ever had cancer? When What Kind How are you being treated? Surgery Chemotherapy Radiation Latex

General Questions	Yes	No
Do you smoke?
Are you nervous? (Not just because you are in a dental office)
Do you have a Mental Health Disorder?
Do you need help sleeping?
Do you have to go to the bathroom often?
Do you get dizzy often or if you stand up too fast?
Do you feel bad if you skip lunch?

NERVES / MUSCLE / BONES	Yes	No
Do you have back problems?
Can you lie in a dental chair comfortably?
Do you have a Neuromascular Disorder? What is it?

IMMUNE SYSTEM	Yes	No
Lupus
Organ Transplant
HIV
AIDS

Name of Physician Phone #

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