Patient Registration
Patient’s Name______Date of Birth______SS#______
Address______City, State, Zip______
Phone Number: Home______Cell______Work______
Email______Best way to contact: EMAIL CELL PHONE HOME PHONE
How did you hear about us?/Referred by______
Employer______Employer Address______
Spouse or Parent/Guardian’s name______Spouse or Parent/Guardian Phone #______
Emergency Contact______Relation______Phone #______
INSURANCE INFORMATION - please fill out if applicable
Insurance Carrier______Employer Name______
Employer Address______Employer Phone #______
Policy Holder Name______Policy Holder Birth date______
Policy Holder Address (if different than above)______
Policy Holder SSN or ID #______Policy Holder Phone #______
Dental History – answers to these questions help us provide safe and effective dental care personalized to your individual needs
Date of your last dental visit______Dr.______Date of Last x-rays______
Do you have any chief concerns ______
If you answer yes to any of the following, please explain:
Are your teeth sensitive to cold, hot, sweets, or pressure?….. Ο Yes Ο No ______
Do your gums bleed when you brush?………………………………….. Ο Yes Ο No ______
Is your mouth dry?………………………………………………………………… Ο Yes Ο No ______
Have you had any periodontal (gum) treatments?………………. Ο Yes Ο No ______
Have you ever had orthodontic (braces) treatment?……………. Ο Yes Ο No ______
Have you ever had problems with previous dental treatment? Ο Yes Ο No ______
Are you currently experiencing dental pain or discomfort?... Ο Yes Ο No ______
Do you have any clicking, popping or discomfort in the jaw?.. Ο Yes Ο No ______
Do you clench or grind your teeth?...... Ο Yes Ο No ______
Do you have earaches or neck pains?...... Ο Yes Ο No ______
Do you have any sores or ulcers in your mouth?...... Ο Yes Ο No ______
Do you feel nervous when coming to the dental office?...... Ο Yes Ο No If yes, what is your biggest concern?______
MEDICAL HISTORY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you receive. Thank you for answering the following questions.
Date of Last Physical Exam______Are you now under the care of a physician Ο Yes Ο No
If yes, what condition is being treated______
Physician Name______Clinic______Phone Number______
If you answer yes to any of the following, please explain:
Have you had a serious illness, operation, hospitalization in the past 5 years?.... Ο Yes Ο No ______
Have you ever had a serious head or neck injury?...... Ο Yes Ο No ______
Do you take, or have you taken, Phen-Fen or Redux?...... Ο Yes Ο No ______
Are you taking bisphosphonates? Eg. Boniva, Aredia, Fosamax…………………………. Ο Yes Ο No ______
Have you taken corticosteroids (cortisone, steroids) in the past 2 years?...... Ο Yes Ο No ______
Are you taking blood thinners?...... Ο Yes Ο No ______
Are you on a special diet?...... Ο Yes Ο No ______
Do you use controlled substances?...... Ο Yes Ο No ______
Are you taking any medications, pills, or drugs? Ο Yes Ο No If yes, Please list all below:
______
______
Women Only:
Are you: Ο Pregnant Ο Nursing Ο Taking Oral contraceptives
Are you allergic to any of the following?
Ο Aspirin Ο Penicillin Ο Codeine Ο Acrylic Ο Metal Ο Latex Ο Local Anesthetics Ο Sulfa Ο Other______
If Yes, please specify type of reaction ______
Check if you have, or have had, any of the following:
Ο Angina Ο High Blood Pressure Ο Lung Disease Ο Rheumatism
Ο Artificial Heart Valve* Ο Low Blood Pressure Ο Frequent Cough Ο AIDS/HIV Positive
Ο Congenital Heart Disorder Ο Diabetes Ο Frequent Headaches Ο Herpes
Ο Heart Attack/Stroke Ο Hypoglycemia Ο Pain in Jaw Joints Ο Cold Sores/Fever Blisters
Ο Heart Murmur* Ο Parathyroid Disease Ο Cancer Ο Venereal Disease/STD
Ο Heart Pace Maker Ο Thyroid Disease Ο Chemotherapy Ο Chemical Dependency
Ο Heart Trouble/Disease Ο Alzheimer’s Disease Ο Radiation Treatments Ο Tobacco Habit
Ο Mitral Valve Prolapse* Ο Artificial Joint* Ο Leukemia Ο Shingles
Ο Irregular Heart Beat Ο Epilepsy or Seizures Ο Tumors or Growths Ο Staph Infection
Ο Rheumatic Fever* Ο Fainting Spells/Dizziness Ο Anemia Ο VRE
Ο Scarlet Fever Ο Kidney Problems Ο Blood Disease
Ο Hepatitis Ο Liver Disease Ο Blood Transfusion
Ο Clostridia Difficile Ο Renal Dialysis Ο Excessive Bleeding
Ο Methicillin Resistant Ο Asthma/Sinus Problems Ο Hemophilia
Ο Staph Aureus Ο Emphysema Ο Sickle Cell Disease
Ο Tuberculosis Ο Breathing Problem Ο Arthritis/Gout * Condition may require medication
Have you ever had any serious illness not listed above? Ο Yes Ο No ______
Any additional information that you feel is important for us to know______
To the best of my knowledge, the questions on these forms have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
______
Signature of Patient, Parent, or Guardian Date