Health History & Registration Form

PATIENT INFORMATION (if Minor)

Personal Details
Last Name Soc Sec #
First Name Guardianís Name
Middle Initial Reference Name
SEX M F Reason for Visit
Birth date (MM/DD/YYYY) Today's Date
Age

PATIENT INFORMATION (if Adult)

Personal Details
Last Name Home Phone Soc Sec #
First Name Cell Phone Birth date (MM/DD/YYYY)
Middle Initial Work Phone Driver's linsense
Marital Status Married Unmarried Email Relation To Patient

Residence Address Mailing Address Previous Address
StreetStreetStreet
Apt Apt Apt
City City City
State State State
Zip Zip Zip

Employer Occupation No.Year's Employed
 
 
Emergency Contact Information Referral Source
Last Name Home PH. Whom may we thank for referring you? :
Family Friend Co-Worker Doctor
First Name Cell PH. Or did you find us on your own:
Yellow Pages Yellow Book Billboard Mail
Radio Insurance Web Sign
Middle Initial Work PH. Magazine Newspaper
Relation To Patient Email Others
 
 
Dental Insurance Information (Primary Carrier) Patient Employer Information
Insuredís Name Insured’s Employer Employer Name
Insurance Co Soc Sec # Employer Address
Insurance Co. Address Group # Employer Phone Number
E-mail Local #
Dental History YES NO Dental History YES NO
HOW LONG SINCE you have seen a dentist? Do your gums BLEED, or feel TENDER or RRITATED?
Last COMPLETE Dental Exam, DATE? Are your teeth sensitive to hot, cold sweets pressure?
Last FULL MOUTH X-RAYS, DATE? Are you unhappy with the APPEARANCE of your teeth?
Are you having PROBLEMS now? Are you aware of GRINDING, or CLENCHING your teeth?
HOW LONG SINCE you have seen a dentist? WHAT? Do you have HEADACHES, EARACHES, or NECK PAINS?
Is your present dental Health POOR? Have you worn BRACES on your teeth? (orthodontics)
Do you wear DENTURES? Do you have DISCOLORED teeth that bother you?
Are you UNHAPPY with your dentures? Would you like your smile to LOOK BETTER or DIFFERENT?
Would you like to know more about PERMANENT REPLACEMENT Do you REGULARLY use DENTAL FLOSS?
Are you APPREHENSIVE about dental treatment?
Have you had any PERIODONTAL (GUM) treatments?
Name of Previous Dentist City Status
How do you feel about your teeth?

MEDICAL UPDATE

Date   Patient Signature   Doctor Signature
   
   
   
   
   
Medical History YES NO
Do you have any CURRENT HEALTH PROBLEMS?
Are you under a PHYSICIANíS CARE now? & For what?
What MEDICATIONS are you currently taking?
Are you ALLERGIC to any MEDICATIONS?
Have you ever taken Fen-Phen/Redux?
Are you PREGNANT?
Do you use cigars/cigarettes, pipe, or chewing tobacco? (circle)

PLEASE TICK YES OR NO OF THE FOLLOWING WHICH YOU HAVE HAD, OR PRESENTLY HAVE

  YES NO     YES NO     YES NO
AIDS/HIV Pos.   Fainting   Pacemaker/heart surgery
Anaphylaxis   Food Allergies   Psychiatric care
Anemia   Glaucoma   Rapid weight gain/loss
Arthritis   Headaches   Radiation treatment
Artificial heart valves   Heart murmur   Respiratory disease
Artificial joints   Heart problems (please describe)   Rheumatic
Asthma   Hemophilia   Shingles
Atopic (allergy prone)   Herpes   Shortness of breath
Back problems   Hepatitis   Skin Rash
Blood disease   High blood pressure   Spina bifida
Cancer   Jaw pain   Stroke
Chemical dependency   Kidney disease   Surgical implant
Chemotherapy   Liver disease   Swelling of feet/ankles
Circulatory problems   Malnutrition   Thyroid disease
Cortisone treatments   Material allergies   Tobacco habit
Cough   latex, wool, metal, chemicals)   Tonsillitis
Cough up blood   Mitral valve prolapse   Tuberculosis
Diabetes   Nervous problems   Ulcer/Colitis
Epilepsy           Venereal disease
Family Physician Phone Email