WELCOME TO OUR OFFICE
REGISTRATION INFORMATION
The information that is require on this questionnaire is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using, and disclosing this information responsibly. PLEASE PRINT
This patient is a(n): ___ ADULT ___ CHILD ___ ADULT UNDER GUARDIAN Name of Guardian______
Dr. ____ Mr. ____ Mrs.____ Ms.____ Miss.____ Referred by: ______
Name: ______Prefer to be called: ______
LAST FIRST INITIAL
Address: ______
STREET APT# CITY POSTAL CODE
Birthday: M ___ D ___ Y ___ Age: ______Email: ______
Home Phone: ______Cell: ______Marital Status: ______Sex: ______
May we call you at work? Yes___ No___ Work Phone:______Employer: ______
Person Responsible for Account: ______Spouse: ______
Address: ______
Do you have insurance? Yes___ No___ Insurance Company: ______
Policy #: ______ID #: ______
Healthcard #: ______
Family Physician ______Phone: ______
Are you under the care of a Medical Specialist? Yes___ No___
Specialist ______Phone: ______
Emergency contact: ______Phone: ______
Relationship: ______
HEALTH HISTORY Please check yes or no to each question. Y / N
1. Are you being treated for any medical condition at present or within the last year? ____
If yes, please explain. ______
______
2. Has there been any change in your general health in the past year?______
______
3. When was your last visit to a physician? ______Last complete exam? ______
Y / N
4. Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs (including herbal remedies)? If yes, please explain. ______
______
5. Have you every had an adverse or unusual reaction to any medication or injections?
(e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic? Please explain:
______
6. Have you ever been advised against taking any specific type of medication? ______
______
7. Do you have any allergies? (e.g. hay fever, food allergies, latex/rubber, or metal
allergies) ______
8. Do you have epilepsy or seizures? ______
9. Have you every fainted during dental or medical treatment ______
10. Do you bleed excessively from a cut or injury, bruise easily, or have any blood
disorders? ______
11. Are you on any cortisone or steroid therapy, or are you on a diet pill therapy? ___
______
12. Do you have any artificial joints? (hip/knee) ______
13. Have you ever been advised to take antibiotics before dental treatment? ______
______
14. Do you have, or have you every had, any heart or blood pressure problems? (heart
attack or stroke) Please explain. ______
______
15. Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial
heart valve) or have you ever had Rheumatic fever? ______
______
16. Do you have or have you ever had chest pain, shortness or breath, or any heart
palpitation without exertion? ______
17. Are you presently suffering from any infection diseases? ______
______
18. Have you ever had Hepatitis, Jaundice, or any Liver Disease? ______
______
19. Do you have any condition that could affect your immune system? (e.g. arthritis,
AIDS, HIV, lupus, IBS, Crohn's disease) Please explain. ______
______
Y / N
20. Have you ever had any malignant disease, or are you presently undergoing any
radiation treatment/chemotherapy? ______
______
21. Indicate which (if any) of the following you presently have, or ever had: PLEASE CIRCLE
Asthma Bronchitis Emphysema Lung Disease
Tuberculosis Diabetes Kidney Disease Thyroid Disease
Glandular Disorder Organ Transplant Medical Implant Intestinal Problems
Stomach Problems Ulcers
22. Do you, or did you smoke? ______Do you drink alcoholic beverages on a regular basis? _____ Do you use recreational drugs? ______
23. Are there any diseases or medical problems that run in your family ______
______
24. Do you currently have, or ever had in the past, any disease, condition, or problem
not listed above? ______
25. Is there anything else about your health we should be made aware of; or do you
wish to speak to the doctor privately about any problem or medical condition? _____
______
WOMEN ONLY
26. Are you taking birth control pills? ______
Are you breast feeding? ______
Are you pregnant? ______
Expected delivery date? ______
Are you aware of your bone mineral density? (Women over 50) ______
Notes: ______
DENTAL HISTORY
1. Is there a dental problem you would like treated immediately? ______
______
2. Date of your last dental visit? ______Last cleaning? ______Last xrays? ______
3. How often do you brush your teeth? ______Do you feel you have bad breath? ____
4. Do you use dental floss? ______Proxabrush? ______Stimudents?______How often? ___
5. Are your teeth sensitive to heat, cold, or sweets? ______
Y / N
6. Have you ever had:
- periodontal treatment? ______
- orthodontic treatment? ______
- bite plate or any other appliance? ______
- bite adjustment? ______
- oral surgery? (mouth/jaw joint, implant, etc) ______
7. Do you have any emotional concerns about dental treatment? ______
______
8. Have you ever had an upsetting experience in a dental office, or any complications
during or following dental treatment? ______
9. Are you unhappy with the appearance of your teeth? ______
10. What would you like to see changed? ______
11. Do you feel your dental health influences your overall health? ______
______
12. On a scale of 1 to 10, 10 being highest, how important is it for you to keep your
natural teeth? ______
GENERAL RELEASE
I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise the office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used, and disclosed within the guidelines or the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.
Signature: ______
circle PATIENT PARENT GUARDIAN PRINT NAME OF GUARDIAN
Reviewed by treating dentist: ______Date: ______