If you are under the care of a physician, please give reason(s) for treatment.

TELL US ABOUT YOUR SYMPTOMS

LAST NAMEFIRST NAME

1. Are you experiencing any pain at this time? If not, please go to question 6.

2. If yes, can you locate the tooth that is causing the pain?

YesNo YesNo

3. When did you first notice the symptoms?

4. Did your symptoms occur suddenly or gradually?

5. Please check the frequency and quality of the discomfort, and the number that most closely reflects the intensity of your pain:

LEVEL OF INTENSITY

(On a scale of 1 to 10) 1 = Mild 10 = Severe

FREQUENCY

QUALITY

12345678910 Constant Sharp

Intermittent Dull

Momentary Throbbing

Occasional

Is there anything you can do to relieve the pain?

If yes, what?

YesNo

Is there anything you can do to cause the pain to increase?

If yes, what?

Yes

No

When eating or drinking, is your tooth sensitive to: Does your tooth hurt when you bite down or chew?

Does it hurt if you press the gum tissue around this tooth?

HeatColdSweets

YesNo YesNo

Does a change in posture (lying down or bending over) cause your tooth to hurt?

6. Do you grind or clench your teeth?

7. If yes, do you wear a night guard?

8. Has a restoration (filling or crown) been placed on this tooth recently?

9. Prior to this appointment, has root canal therapy been initiated on this tooth?

Is there anything else we should know about your teeth, gums, or sinuses that would assist us in our

Yes No Yes No Yes No Yes No Yes No

diagnosis?

Signed: Patient or ParentDate

TELL US ABOUT YOUR HEALTH

LAST NAMEFIRST NAME

How would you rate your health? Please circle one. Excellent Good Fair Poor

When did you have your last physical exam?

If you are under the care of a physician, please give reason(s) for treatment.

Physician?s Name, Address, and Telephone Number:

NameAddress

CityStateZipTelephone

Have you ever had any kind of surgery?

YesNo

If yes, what kind?Date

Date

Have you ever had any trouble with prolonged bleeding after surgery? Do you wear a pacemaker or any other kind of prosthetic device?

Are you taking any kind of medication or drugs at this time?

If yes, please give name(s) of the medicine(s) and reason(s) for taking them:

Yes No Yes No Yes No

NameReason

Have you ever had an unusual reaction to an anesthetic or drug (like penicillin)?

YesNo

Are you allergic to Latex or any other substances or materials?

YesNo

If so, please explain

If female, are you pregnant?

YesNo

Is there any other information that should be known about your health?

Signed: Patient or ParentDate:

Dental History Interview

After starting the interview and determining the nature of the chief complaint, the clinician continues the conversation by documenting the sequence of events that initiated the request for an evaluation. The dental history is divided into five basic directions of questioning: localization, commencement, inten- sity, provocation and attenuation, and duration.

Localization. ?Can you point to the offending tooth?? Often the patient can point to or tap the offending tooth. This is the most fortunate scenario for the clinician because it helps direct the interview toward the events that might have caused any particular pathosis in this tooth. In addition, localization allows subsequent diagnostic tests to focus more on this particular tooth. When the symptoms are not well localized, the diagnosis is a greater challenge.

Commencement. ?When did the symptoms first occur?? A patient who is having symptoms often remembers when these symptoms started. Sometimes the patient will even remember the initiating event: it may have been spontane- ous in nature; it may have begun after a dental visit for a restoration; trauma may be the etiology, biting on a hard object may have initially produced the symptoms, or the initiating event may have occurred concurrently with other symptoms (sinusitis, headache, chest pain, etc.). However, the clinician should resist the tendency to make a premature diagnosis based on these circumstances. The clinician should not simply assume ?guilt by association? but instead should use this information to enhance the overall diagnostic process.

Intensity. ?How intense is the pain?? It often helps to quantify how much pain the patient is actually having. The clinician might ask, ?On a scale from 1 to 10, with 10 the most severe, how would you rate your symptoms?? Hypotheti- cally, a patient could present with ?an uncomfortable sen- sitivity to cold? or ?an annoying pain when chewing? but might rate this ?pain? only as a 2 or a 3. These symptoms certainly contrast with the type of symptoms that prevent a patient from sleeping at night. Often the intensity can be subjectively measured by what is necessary for the diminu- tion of pain?for example, acetaminophen versus a narcotic pain reliever. This intensity level may affect the decision to treat or not to treat with endodontic therapy. Pain is now considered a standard vital sign, and documenting pain intensity (scale of 0 to 10) provides a baseline for compari- son after treatment.

Provocation and attenuation. ?What produces or reduces the symptoms?? Mastication and locally applied temperature changes account for the majority of initiating factors that cause dental pain. The patient may relate that drinking something cold causes the pain or possibly that chewing or biting is the only stimulus that ?makes it hurt.? The patient might say that the pain is only reproduced on ?release from biting.? On occasion, a patient may present to the dental office with a cold drink in hand and state that the symptoms can only be reduced by bathing the tooth in cold water. Nonprescription pain relievers may relieve some symptoms, whereas narcotic medication may be required to reduce others (see Chapter 4 for more information). Note that patients who are using narcotic as well as non-narcotic (e.g., ibuprofen) analgesics may respond differently to questions and diagnostic tests, thereby altering the validity of diag- nostic results. Thus, it is important to know what drugs patients have taken in the previous 4 to 6 hours. These provoking and relieving factors may help the clinician to determine which diagnostic tests should be performed to establish a more objective diagnosis.

Duration. ?Do the symptoms subside shortly, or do they linger after they are provoked?? The difference between a cold sensitivity that subsides in a few seconds and one that sub- sides in minutes may determine whether a clinician repairs a defective restoration or provides endodontic treatment. The duration of symptoms after a stimulating event should be recorded to establish how long the patient felt the sensation in terms of seconds or minutes. Clinicians often first test control teeth (possibly including a con- tralateral ?normal? tooth) to define a ?normal? response for the patient; thus, ?lingering? pain is apparent when compar- ing the duration between the control teeth and the sus- pected tooth.

With the dental history interview complete, the clinician has a better understanding of the patient?s chief complaint and can concentrate on making an objective diagnostic evaluation,although the subjective (and artistic) phase of making a diagnosis is not yet complete and will continue after the more objective testing and scientific phase of the investigatory process.

Date: 2016-06-12; view: 242