Patient Registration Form

DATE:

EMAIL:

NAME:

I PREFER TO BE CALLED:

Gender

Male Female

BIRTHDAY:

SS#:

DRIVERS LICENSE#:

HOME ADDRESS:

STREET:

CITY:

STATE:

ZIP:

HOME PHONE:

WORK PHONE:

CELL PHONE:

May we leave a voice message on these devices?

Yes No

WHOM MAY WE THANK FOR REFERRING YOU?

EMPLOYER:

HOW LONG THERE?

EMPLOYERS ADDRESS:

OCCUPATION:

NEIGHBOR OR RELATIVE NOT LIVING WITH YOU

NAME:

RELATION:

ADDRESS:

PHONE NUMBER:

RESPONSIBLE PARTY INFORMATION IF OTHER THAN SELF

NAME:

RELATION:

PHONE NUMBER:

EMPLOYER:

SOCIAL SECURITY #:

BILLING ADDRESS:

SPOUSE INFORMATION

CIVIL STATUS

MARRIED SINGLE DIVORCED WIDOWED SEPARATED

BIRTHDATE:

SPOUSE NAME:

PHONE NUMBER:

PRIMARY INSURANCE INFORMATION

DENTAL COVERAGE?

YES NO

MEDICAL COVERAGE?

YES NO

ORTHODONTIC?

YES NO

INSURANCE CO. NAME:

PHONE#:

GROUP PLAN #:

INSURANCE CO. ADDRESS:

STREET:

CITY:

STATE:

ZIP:

INSURED’S NAME:

INSURED’S SS#:

INSURED’S BIRTH DATE

RELATION TO PATIENT:

INSURED’S EMPLOYER:

EMPLOYER’S ADDRESS:

STREET:

CITY:

STATE:

ZIP:

SECONDARY INSURANCE

INSURANCE CO. NAME:

PHONE#:

GROUP PLAN #:

INSURANCE CO. ADDRESS:

STREET:

CITY:

STATE:

ZIP:

INSURED’S NAME:

INSURED’S SS#:

INSURED’S BIRTH DATE:

REALTION TO PATIENT:

INSURED’S EMPLOYER:

EMPLOYER’S ADDRESS:

STREET:

CITY:

STATE:

ZIP:

Why have you come to the dentist today?

Are you currently in pain?

Yes No

Do you require antibiotics before dental treatment? Example: Total joint replacement: knee, hip, shoulder etc. or Heart valve replacement

Yes No

If yes, what was it and date of placement?

Have you experienced problems associated with Any previous dental work?

Yes No

Do you now or have you ever experienced pain / discomfort In your jaw joint ?

Yes No

Do you floss daily?

Yes No

Brush Daily?

Yes No

How long do you use a toothbrush before replacing it?

Do you use anything in addition to your brush and floss?

Yes No

If yes, what?

How low long has it been since you have seen a dentist?

6 months to 1 year 1 year - 3 years 4 years to 6 years Over 7 years

How long has it been since you had your Teeth cleaned?

6 months to 1 year 1 year to 3 years 4 years to 6 years Over 7 years

Do you Smoke or use tobacco in any other form?

Yes No

Do your gums bleed?

Yes No

Have you ever had periodontal disease?

Yes No

Are any of your teeth loose?

Yes No

Are your teeth sensitive to heat, cold or sweets?

Yes No

Are you happy with the way your smile looks?

Yes No

If Not, what would you change?

Previous dentist:

Why did you leave?

What did you like most I least about any dentist you have seen.

Your current physical health is:

Good Fair Poor

Arc you currently under the care of a physician?

Yes No

If yes please explain:

Physicians Name:

Address:

Phone #:

Date of last visit:

Are you taking or scheduled to begin taking either of the medications, alendronate (fosamax) or residronate (Actonel) For osteoporosis or paget's disease:

Yes No

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from pagets' disease, multiple Myeloma or metastatic cancer

Yes No

Date treatment began:

Doctor:

Are you under a physician's care now?

Yes No

If yes

Have you ever been hospitalized or had a major operation?

Yes No

If yes

Have you ever had a serious head or neck injury?

Yes No

If yes

Are you taking any medications, pills, or drugs?

Yes No

If yes

Do you require a PRE-MED prior to dental treatment?

Yes No

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

If yes

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

If yes

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Antibiotics

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other

If yes

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

High Blood Pressure

Yes No

Scarlet Fever

Yes No

Artificial Joint

Yes No

Fainting Spells/Dizziness

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Tuberculosis

Yes No

Congenital Heart Disorder

Yes No

Heart Trouble/Disease

Yes No

Steroid Therapy

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Herpes

Yes No

Arthritis/Gout

Yes No

Artificial Heart Valve

Yes No

Excessive Thirst

Yes No

Blood Disease

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Cancer

Yes No

Tonsillitis

Yes No

Cold Sores/Fever Blisters

Yes No

Heart Pacemaker

Yes No

Psychiatric Care

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Rheumatic Fever

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Hypoglycemia

Yes No

Kidney Problems

Yes No

Breathing Problems

Yes No

Bruise Easily

Yes No

Thyroid Disease

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Radiation Treatments

Yes No

Recent WeightLoss

Yes No

Renal Dialysis

Yes No

Emphysema

Yes No

High Cholesterol

Yes No

Shingles

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Chemotherapy

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Convulsions

Yes No

Have you ever had any serious illness not listed above?

Yes No

If yes

List All Medications/ Natural Supplements

To the best of my knowledge, the questions on this form 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.

Name of Patient, Parent or Guardian

Date

Your information will be encrypted.