Registration & Health History Form

Registration & Health History Form
Registration Form Today's Date:*

MonthDayYear
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Last*
First*
Middle*
Your Business/Cell Phone: Include area code*
Email:*
example@example.com
Mail Address*

Address

Street Address Line 2

CityState

Zip
Physical Address*

Address

Street Address Line 2

CityState

Zip
Occupation and company you work for*
Date of Birth:*

MonthDayYear
Date
Sex: Male or Female*

FemaleMale
Marital Status*

SingleMarriedDivorcedWidow
SS# or Patient ID:*
Health History Height:
Weight
Emergency Contact:*
Relationship of emergency contact:*
Emergency contact Home Phone/Cell : Include area code*
If you are completing this form for another person, what is your relationship to that person
Please check all the boxes that apply. A check mark indicates you have had or have this condition. If you do not have any of the conditions in a specific section check ..None

Do you have any of the following diseases or problems:
Are you experiencing dental pain? (check all that apply)*

Occasional, lasts secondsConstant & severe, lingers hoursConstant with swellingSpontaneous, lingers hoursTrauma associatedTooth broke recentlyTooth broke months to 1 year agoTooth has a root canal and or crownTooth is an upper wisdom toothTooth is a lower wisdom toothTooth is a front toothPain is in my gumsPain radiatesNone, no painOther
Active Tuberculosis*

Been exposed to anyone with tuberculosisPersistent cough greater than a 3 week durationCough that produces blood.Been exposed to anyone with this conditionNONE
When was the last time you saw a dentist?*
Date of last dental X rays:

MonthDayYear
Has a physician or dentist recommended that you take antibiotics prior to your dental treatment for any reason other than an infection*

YesNo
If you answered "Yes" to the above question.... What antibiotic were you prescribed and for what reason?
What is the reason for your dental visit today? Please be detailed and specific. Which tooth and area, upper or lower, right or left, when did the problem start, what kind of pain, how long does it last etc.*
Dental Information (Check all that apply)*

Do your gums bleed when you brush or floss?Are your teeth sensitive to cold, hot, sweets or pressure?Is your mouth dry?Have you had any periodontal (gum) treatments?Have you ever had orthodontic (braces) treatment?Have you had any problems associated with previous dental treatment?Do you have earaches or neck pains?Do you have any clicking, popping or discomfort in the jaw?Do you brux or grind your teeth?Do you have sores or ulcers in your mouth?Do you wear dentures or partials?Have you ever had a serious injury to your head or mouth?NONEOther
Are you under the care of a physician*

YesNo
If yes, what condition is being treated?
Have you had a serious illness, operation or been hospitalized in the past 5 years?*

YesNo
What operation or hospitalization did you have?
Your primary Physician Name:
Physician address/City/State/Zip:
Physician phone number
Are you taking any over the counter medicine(s) ?*

YesNo
Are taking any prescribed medicine?*

YesNo
Please list all over the counter medications. Include all vitamins, natural or herbal preparations and/or dietary supplements.*
Are you taking any doctor prescribed medicine(s), list them below?*
Date of last physical exam:

MonthDayYear
Date
Do you use any controlled substances (drugs)*

YesNo
Do you use smoke marijuana or use any medicinal marijuana products?*

YesNo
Joint replacement. Have you had an orthopedic total joint (hip, Knee, elbow) replacement?*

YesNo
If yes, to a joint replacement, when -approximate month and year?
If yes, have you had any complications with the joint replacement?
Do you smoke or drink (check all that apply)*

NoneSmoke cigarettes or use chew tobaccoDrink occasionally during social gatheringsDrink on a daily basis beer, wine or hard liquorOther
Are you taking or are scheduled to start taking an antiresorptive agent for osteoporosis or or Paget's disease? (check what applies)*

NoneFosamaxActonelAteviaBoniviaReclastProlia
Date Anti-resorptive Treatment began:

MonthDayYear
Date
Since 2001, were you treated or are presently scheduled to begin treatment for bone pain, hypercalcemia or skeletal complications resulting form Paget's disease, multiple myeloma or metastatic cancer with*

NoneArediaZometaXGEVA
Date Treatment began:

MonthDayYear
Date
WOMEN ONLY are you

NonePregnantTaking birth control pillsNursingOther
Number of weeks pregnant
Are you allergic to any of the medications listed or have other allergies?*

No allergiesLocal AnesthesiaAspirinPenicillin or other antibioticsBarbiturates, sedatives or sleeping pillsSulfa drugsCodeine or other narcoticsMetalsLatexHay fever/seasonalFood, dairyOther
Do you have or have had any of the following Cardiac or Vascular conditions?*

NoneArtificial Heart ValvePrevious infectious endocarditisDamaged heart vlaveCongenital Heart disease repaired in last 6 months and or with defectsCongenital heart diseaseAnginaCardiovascular diseaseArteriosclerosisCongestive heart failureHeart AttackHeart MurmurMitral Valve ProlapsePacemakerRheumatic FeverRheumatic heart diseaseAnemiaAbnormal BleedingHemophiliaAids or HIV InfectionStroke if yes indicate in the box belowBlood transfusion if yes indicate when in the box belowOther
List dates of Stroke and or Blood transfusion
Do you have or have had any of the following autoimmune, arthritis, cancer conditions*

NoneArthritisAutoimmune diseaseRheumatoid arthritisSystemic lupus erythematosisAsthmaBronchitisEmphysemaSinus troubleTuberculosisCancer/Chemotherapy/Radiation TreatmentChest pain upon exertionChronic painDiabetes Type I or IIEating disorderMalnutritionGastrointestinal diseaseGE Reflux/persistent heart burnUlcersThyroid problemsOther
Do you have or have had any of following conditions*

NoneGlaucomaHepatitis, jaundice, liver diseaseEpilepsyFainting spells or seizuresNeurological disorderSleep disorderDo you snoreMental health disorderRecurrent infectionsKidney problemsNight sweatsOsteoporosisPersistent swollen glands in neckSevere headaches/migrainesSevere rapid weight lossSexually transmitted diseaseExcessive urinationOther
Do you have any disease, condition or problem not listed above that I should know about? Please explain:*
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Type in the patients name*
Signature of Patient/Legal Guardian:*

Clear
Today's Date*

MonthDayYear
Comments:
Should be Empty:

Registration & Health History Form

Please check all the boxes that apply. A check mark indicates you have had or have this condition. If you do not have any of the conditions in a specific section check ..None