WELCOME TO OUR OFFICE



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: ________________________

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