Patient questionnaire forms list

Dentrix Ascend provides questionnaires for gathering demographics, insurance information, dental history, and medical history. Dentrix Ascend also provides a COVID-19 questionnaire.

Note: Patients whose records do not have Spanish as their preferred language will see the English version. Patients whose records have Spanish as their preferred language will see the Spanish version.

Demographics

This questionnaire includes the following questions:

• Demographics 1 of 4:

  

  Respond to the following questions regarding the patient:

  • First Name - Patient's first name.

  • Last Name - Patient's last name.

  • What name does the patient prefer to go by? - Enter the patient's name or nickname.

  • Birth Date - Specify the patient's birth date:

    • Month - Select the month.

    • Day - Enter the day.

    • Year - Enter the year.

  • Gender - Select Male, Female, or Other.

  • SSN - Enter the patient's Social Security Number.

  • Email Address - Enter the patient's email address.

  • Phone Number - Specify the patient's phone number:

    • Country - US is selected by default, but you can select a different country.

    • Number - Enter the number.

    • Type - Select Home, Mobile, or Work.

  • Address Line 1 - Enter the patient's street address.

  • Address Line 2 - Enter the rest of the address, if applicable.

  • City - Enter the city.

  • State/Province/Region - Enter the state.

  • Postal Code - Enter the ZIP Code.

  • Who is filling out the form today? - Select Patient or Other.

    • With Other selected, the following questions are available:

      • Please provide your first and last name:

        • First Name - Enter your first name.

        • Last Name - Enter your last name.

      • Phone Number - Specify your phone number:

        • Country - US is selected by default, but you can select a different country.

        • Number - Enter the number.

      • Who has legal custody of the patient? - Enter the name of the person.

      • Primary Contact Details - who should we contact for scheduling?:

        • Primary Contact Name - Enter the primary contact person's first and last name.

        • Relationship to Patient - Enter the contact's relationship to the patient.

        • Phone Number - Specify the contact's phone number:

          • Country - US is selected by default, but you can select a different country.

          • Number - Enter the number.

        • Address Line 1 - Enter the contact's street address.

        • Address Line 2 - Enter the rest of the street address, if applicable.

        • City - Enter the city.

        • State/Province/Region - Enter the state.

        • Postal Code - Enter the ZIP Code.

    • With Patient selected, there are no additional questions.

  • How did you hear about us? - Enter the name of the referral source.

• Demographics 2 of 4:

  

  Respond to the following question regarding who is financially responsible for charges that the patient may incur for dental services and products:

  • Is the patient also the guarantor? - Select No or Yes.

    • With No selected, the following questions are available:

      • Guarantor First Name - Enter the guarantor's firs name.

      • Guarantor Last Name - Enter the last name.

      • Relationship to Patient - Enter the guarantor's relationship to the patient.

      • Phone Number - Specify the guarantor's phone number:

        • Country - US is selected by default, but you can select a different country.

        • Number - Enter the number.

      • Address Line 1 - Enter the guarantor's street address.

      • Address Line 2 - Enter the rest of the address, if applicable.

      • City - Enter the city.

      • State/Province/Region - Enter the state.

      • Postal Code - Enter the ZIP Code.

    • With Yes selected, there are no additional questions.

• Demographics 3 of 4:

  

  Respond to the following questions regarding the patient's employment and PHI:

  • Employment Details - Specify the patient's employment details:

    • Occupation - Enter the patient's occupation.

    • How long? - Enter the length of time that the patient has been employed by his or her current employer.

    • Employer Name - Enter the name of the patient's employer.

  • Please list 2 contact names to whom practice can release PHI information (HIPAA):

    • First Name - Enter the name of the first person.

    • Last Name - Enter the last name of the first person.

    • Phone Number - Specify the phone number of the first person:

      • Country - US is selected by default, but you can select a different country.

      • Number - Enter the number.

    • First Name - Enter the name of the second person.

    • Last Name - Enter the last name of the second person.

    • Phone Number - Specify the phone number of the second person:

      • Country - US is selected by default, but you can select a different country.

      • Number - Enter the number.

• Demographics 4 of 4:

  

  Respond to the following questions regarding the patient's emergency contact person, and then the patient or patient's representative signs the form:

  • Emergency Contact - Specify the patient's emergency contact person:

    • First Name - Enter the first name.

    • Last Name - Enter the last name.

    • Phone Number - Specify the emergency contact's phone number.

      • Country - US is selected by default, but you can select a different country.

      • Number - Enter the number.

  • Signature - Use the mouse (click and drag) or a finger (for a touch screen only) to sign the questionnaire.

Dental Insurance

This questionnaire includes the following questions:

• Dental Insurance 1 of 2:

  

  Respond to the following question regarding the patient's dental insurance coverage:

  • Do you have dental insurance? - Select Yes or No.

    • With Yes selected, the following questions are available:

      • Name of Insured - Enter the subscriber's full name.

      • Insured's Birth Date - Specify the subscriber's birth date:

        • Month - Select the month.

        • Day - Enter the day.

        • Year - Enter the year.

      • Insured's Address Line 1 - Enter the subscriber's street address.

      • Insured's Address Line 2 - Enter the rest of the street address, if applicable.

      • Insured's City - Enter the city.

      • Insured's State - Enter the state.

      • Insured's Postal Code - Enter the ZIP Code.

      • Patient's Relationship to Insured - Enter the subscriber's relationship to the patient.

      • Insured's Employer Name - Enter the name of the subscriber's employer.

      • Employer's Address Line 1 - Enter the street address of the subscriber's employer.

      • Employer's Address Line 2 - Enter the rest of the street address, if applicable.

      • Employer's City - Enter the city.

      • Employer's State - Enter the state.

      • Employer's Postal Code - Enter the ZIP Code.

      • Carrier Name - Enter the name of the insurance carrier.

      • Plan Name - Enter the name of the insurance plan.

      • ID # - Enter the subscriber's ID.

      • Group # - Enter the insurance plan's group number.

      • Insurance Company Phone Number - Specify the carrier's phone number:

        • Country - US is selected by default, but you can select a different country.

        • Number - Enter the number.

      • Insurance's Address Line 1 - Enter the carrier's street address.

      • Insurance's Address Line 2 - Enter the rest of the street address, if applicable.

      • Insurance's City - Enter the city.

      • Insurance's State - Enter the state.

      • Insurance's Postal Code - Enter the ZIP Code.

    • With No selected, there are no additional questions.

• Dental Insurance 2 of 2:

  

  Respond to the following question regarding the patient's secondary dental insurance coverage, and then the patient or patient's representative signs the form:

  • Do you have Secondary Insurance? - Select Yes or No.

    • With Yes selected, the following questions are available:

      • Name of Insured - Enter the subscriber's full name.

      • Insured's Birth Date - Specify the subscriber's birth date:

        • Month - Select the month.

        • Day - Enter the day.

        • Year - Enter the year.

      • Insured's Address Line 1 - Enter the subscriber's street address.

      • Insured's Address Line 2 - Enter the rest of the street address, if applicable.

      • Insured's City - Enter the city.

      • Insured's State - Enter the state.

      • Insured's Postal Code - Enter the ZIP Code.

      • Patient's Relationship to Insured - Enter the subscriber's relationship to the patient.

      • Insured's Employer Name - Enter the name of the subscriber's employer.

      • Employer's Address Line 1 - Enter the street address of the subscriber's employer.

      • Employer's Address Line 2 - Enter the rest of the street address, if applicable.

      • Employer's City - Enter the city.

      • Employer's State - Enter the state.

      • Employer's Postal Code - Enter the ZIP Code.

      • Carrier Name - Enter the name of the insurance carrier.

      • Plan Name - Enter the name of the insurance plan.

      • ID # - Enter the subscriber's ID.

      • Group # - Enter the insurance plan's group number.

      • Insurance Company Phone Number - Specify the carrier's phone number:

        • Country - US is selected by default, but you can select a different country.

        • Number - Enter the number.

      • Insurance's Address Line 1 - Enter the carrier's street address.

      • Insurance's Address Line 2 - Enter the rest of the street address, if applicable.

      • Insurance's City - Enter the city.

      • Insurance's State - Enter the state.

      • Insurance's Postal Code - Enter the ZIP Code.

    • With No selected, there are no additional questions.

  • Signature - Use the mouse (click and drag) or a finger (for a touch screen only) to sign the questionnaire.

Dental History

This questionnaire includes the following questions:

• Is the patient a minor? - Select Yes or No.

  • With Yes selected, the following questions are available:

    

    Respond to the following questions regarding the patient's dental history:

    • Is this your child's first dentist visit? - Select No or Yes.

      • With No selected, the following questions are available:

        • Please provide the following provider details:

          • Provider Name - Enter the name of the dentist.

          • Provider Phone Number - Specify the dentist's phone number:

            • Country - US is selected by default, but you can select a different country.

            • Number - Enter the number.

      • With Yes selected, there are no additional questions.

    • Does your child have any of the following?:

      • Cavities / Decay - Select No or Yes.

      • Lip Sucking / Biting - Select No or Yes.

      • Speech Problems - Select No or Yes.

      • Nail Biting - Select No or Yes.

      • Pacifier / Thumb / Finger Sucking - Select No or Yes.

      • Mouth Breathing - Select No or Yes.

      • Tongue Thrust - Select No or Yes.

      • Nursing / Bottle Habits - Select No or Yes.

      • Jaw Problems - Select No or Yes.

      • Grinding Teeth - Select No or Yes.

      • Has the patient ever had orthodontic treatment (Braces)? - Select No or Yes.

      • Has the patient ever had any pain/tenderness in their jaw joint (TMJ/TMD)? - Select No or Yes.

  • With No selected, the following questions are available:

    

    Respond to the following questions regarding the patient's dental history:

    • Reason for visit - Enter the reason that the patient is being seen today.

    • Date of last dental visit - Select 0 - 6 months ago, 6 months - 1 year ago, 1 - 2 years ago, or More than 2 years ago.

    • Date of last dental X-rays - Specify when the patient last had dental X-rays taken:

      • Month - Select the month.

      • Day - Enter the day.

      • Year - Enter the year.

    • How often do you floss? - Select 2-3 times a week, Daily, Never, or Weekly.

    • How often do you brush? - Select 2-3 times a day, 2-3 times a week, Daily, Never.

    • Bad Breath - Select No or Yes.

    • Bleeding, Red, Swollen Gums - Select No or Yes.

    • Broken/Loose teeth or fillings - Select No or Yes.

    • Clicking or popping jaw - Select No or Yes.

    • Grinding teeth - Select No or Yes.

    • Pain around ear/side of face - Select No or Yes.

    • Sores/Blisters in mouth - Select No or Yes.

    • List any other dental concerns/pain - Enter any other dental issues or pain the patient is experiencing.

    • What did you like the most about your previous dental office? - Select No or Yes.

    • What did you like the least about your previous dental office? - Select No or Yes.

    • Are you interested in whitening your smile? - Select No or Yes.

    • Are you happy with your smile? If not, what would you change? - Enter a response about the patient's smile.

• Signature - Use the mouse (click and drag) or a finger (for a touch screen only) to sign the questionnaire.

Medical History

This questionnaire includes the following questions:

• Medical History 1 of 6:

  

  Respond to the following questions regarding the patient's medical history:

  • Allergy - Aspirin - Select No or Yes.

  • Allergy - Codeine - Select No or Yes.

  • Allergy - Latex - Select No or Yes.

  • Allergy - Local Anesthetic - Select No or Yes.

  • Allergy - Penicillin - Select No or Yes.

  • Allergy - Sulfa - Select No or Yes.

  • List any other allergies - Enter any other allergies that the patient has.

• Medical History 2 of 6:

  

  Respond to the following questions regarding the patient's medical history:

  • Abnormal (High/Low) Blood Pressure - Select No or Yes.

  • AIDS/HIV - Select No or Yes.

  • Anemia / Bleeding Problems - Select No or Yes.

  • Artificial Heart Valves - Select No or Yes.

  • Blood Disease - Select No or Yes.

  • Congenital Heart Lesions - Select No or Yes.

  • Heart Problems - Select No or Yes.

  • Pacemaker - Select No or Yes.

• Medical History 3 of 6:

  

  Respond to the following questions regarding the patient's medical history:

  • Arthritis / Rheumatism / Gout - Select No or Yes.

  • Artificial Joints / Bones - Select No or Yes.

  • Asthma - Select No or Yes.

  • Cancer - Select No or Yes.

  • Chemotherapy - Select No or Yes.

  • Diabetes - Select No or Yes.

  • Emphysema - Select No or Yes.

  • Glaucoma - Select No or Yes.

  • Radiation Treatment (Xray/Cobalt) - Select No or Yes.

  • Shortness of Breath (Breathing Problems) - Select No or Yes.

  • Sinus Trouble - Select No or Yes.

  • Stroke - Select No or Yes.

  • Thyroid Problems - Select No or Yes.

  • Tuberculosis - Select No or Yes.

  • Tumor / growth on head / neck - Select No or Yes.

  • Ulcer - Select No or Yes.

• Medical History 4 of 6:

  

  Respond to the following questions regarding the patient's medical history:

  • Epilepsy - Select No or Yes.

  • Fainting / Dizziness - Select No or Yes.

  • Headaches (Frequent) - Select No or Yes.

  • Hepatitis - Select No or Yes.

  • Herpes - Select No or Yes.

  • Kidney Disease - Select No or Yes.

  • Liver Disease - Select No or Yes.

  • Nervous Problems - Select No or Yes.

  • Psychiatric Care - Select No or Yes.

  • List any other medical issues you have - Enter any other medical issues that the patient has.

  • List any serious Illnesses / surgeries / hospitalizations - Enter any serious, past medical issues that the patient experienced.

  • Are you taking any medications? (required) - Select No or Yes.

    • With Yes selected, the following question is available:

      • List medications you are taking - Enter the names of the medications that the patient is taking.

    • With No selected, there are no additional questions.

• Medical History 5 of 6:

  

  Respond to the following questions regarding the patient's medical history:

  • Do you Smoke? - Select No or Yes.

  • Do you drink Alcohol? - Select No or Yes.

  • High Sugar intake? - Select No or Yes.

• Medical History 6 of 6:

  

  Respond to the following questions regarding the patient's medical history, and then the patient or patient's representative signs the form:

  • Pregnant - Select No or Yes.

  • Nursing - Select No or Yes.

  • Is the patient under the care of a physician? - Select No or Yes.

    • With Yes selected, the following questions are available:

      • Physician Name - Enter the name of the doctor.

      • Physician Phone Number - Specify the doctor's phone number:

        • Country - US is selected by default, but you can select a different country.

        • Number - Enter the number.

    • With No selected, there are no additional questions.

  • Has the patient ever been hospitalized? - Select No or Yes.

    • With Yes selected, the following question is available:

      • Please state the reason for hospitalization - Enter the reason.

    • With No selected, there are no additional questions.

  • Is the patient physically, mentally or emotionally impaired? - Select No or Yes.

  • Describe the patient's current physical health - Select Fair, Good, or Poor.

  • Signature - Use the mouse (click and drag) or a finger (for a touch screen only) to sign the questionnaire.

COVID-19 Patient Screening

This questionnaire includes the following questions:

Respond to the following questions regarding the patient's risk, exposure, and symptoms relative to COVID-19, and then the patient or patient's representative signs the form:

• Do you have a fever or have you felt hot or feverish recently (14-21 days)? - Select No or Yes.

• Are you having shortness of breath or other difficulties breathing? - Select No or Yes.

• Do you have a cough? - Select No or Yes.

• Do you have any flu-like symptoms, such as gastrointestinal upset, headache or fatigue? - Select No or Yes.

• Have you experienced recent loss of taste or smell? - Select No or Yes.

• Have you had any contact with any confirmed COVID-19 positive patients? - Select No or Yes.

• Is your age over 60? - Select No or Yes.

• Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? - Select No or Yes.

• Have you traveled in the past 14 days to any regions affected by COVID-19? - Select No or Yes.

• Signature - Use the mouse (click and drag) or a finger (for a touch screen only) to sign the questionnaire.