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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