New Patient Registration
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Emergency Contact Info
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Medical Information
Current Dentist (name and number)
Date of last Xrays
Current Physician (name and number)
Submit
Medical History
Do you have any of the following diseases or problems?
Active tuberculosis?
Persistent cough greater than 3 weeks?
Cough that produces blood?
Been exposed to anyone with tuberculosis?
Are you under the care of a physician?
Yes
No
If yes, include name, address, phone number and reason.
Are you in good health?
Yes
No
Have there been any changes in your health in the past year?
Yes
No
If yes, please explain.
Date of last physical exam?
Have you been hospitalized in the past 5 years?
Yes
No
If yes, list reason and date.
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.
Do you wear contact lenses?
Yes
No
Do you use controlled substances (drugs)?
Yes
No
Type option 4
If yes, which ones?
Do you use tobacco?
Yes
No
If yes, what kind, how often.
Do you drink alcohol?
Yes
No
If yes, how many drinks in last 24 hours? How many per week?
How interested are you in stopping drugs, alcohol or tobacco use?
Very
Somewhat
Not interested
Not applicable
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?
Yes
No
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeons name and number.
Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)?
Yes
No
If yes, what type, dosage and when was it taken?
Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?
Yes
No
If yes, what type, dosage and when was it taken?
For which condition?
Bone pain
Paget’s disease
Multiple myeloma
Metastatic cancer
Other
Are you?
Taking birth control or hormone replacement
Nursing
Pregnant or trying to get pregnant
Are you allergic to or had a reaction to the following?
Local anesthetics
Barbiturates
Codeine or other narcotics
Latex
Hay fever
Food
Penicillin or other antibiotics
Sulfa drugs
Metals
Iodine
Animals
Other
If yes to any please specify type and reaction.
Please indicate if you have or have had any of the following diseases or problems.
Cardiovascular disease
Congestive heart failure
Low blood pressure
Mitral valve prolapse
Rheumatic heart disease
Blood transfusion
Arthritis
Systemic lupus erythematous
Emphysema
Chest pain upon exertion
Eating disorder
GI reflux/ persistent heart burn
Angina
Heart attack
High blood pressure
Pacemaker
Abnormal bleeding
Hemophilia
Autoimmune disease
Asthma
Sinus trouble
Chronic pain
Malnutrition
Ulcers
Arteriosclerosis
Heart murmur
Other congenital heart defect
Rheumatic fever
Anemia
AIDS/HIV
Rheumatoid arthritis
Bronchitis
Cancer/chemotherapy/radiation
Diabetes 1 or 2
Gastrointestinal disease
Thyroid problem
Stroke
Epilepsy
Sleep disorder
Recurrent infection
Osteoporosis
Severe or rapid weight loss
Glaucoma
Fainting spells or seizures
Snoring
Kidney problems/dialysis
Persistent swollen glands in neck
Sexually transmitted disease
Damaged heart valves
Hepatitis, jaundice or ulcers
Neurological disorder
Mental health disorder
Night sweats
Severe headaches/ migraines
Excessive urination
Herpes, cold sores, fever blisters
Other
If yes to any, list dates, kinds, controlled or uncontrolled
If yes to any of the following CHD conditions, antibioticprophylaxis is recommended. Consult physician.
Artificial (prosthetic) valve
Previous infective endocarditis
Damaged valves in transplanted heart
CHD; unrepaired cyanotic CHD
CHD; repaired completely in last 6 months
CHD; repaired with residual defects
Has a physician or dentist recommended that you take antibiotics prior to dental treatment?
Yes
No
Do you have any diseases or problems not listed above that you think I should know about?
Yes
No
If yes, what?
Grind your teeth?
Present
Past
Never
Bite your cheek?
Present
Past
Never
Tongue thrust?
Present
Past
Never
Mouth breather?
Present
Past
Never
Bulimic/ anorexic?
Present
Past
Never
Cigar/cigarette?
Present
Past
Never
Pipe?
Present
Past
Never
Bite nails?
Present
Past
Never
Smokeless tobacco?
Present
Past
Never
Suck your thumb/finger?
Present
Past
Never
Use a toothpick or stimulator?
Present
Past
Never
Use chewing gum?
Present
Past
Never
Type option 4
Eat candy?
Present
Past
Never
Drink soft drinks?
Present
Past
Never
If present or past to any, please list when, how often and what kind if applicable.
How often do you brush? When?
How often do you floss? When?
Do you use mouthwash? What type?
Other types of oral health instruments?
Personal or family history of oral cancers?
Yes
No
High risk
Are you currently experiencing pain in your mouth?
Yes
No
If yes, where at, what type and for how long?
Are your teeth sensitive to hot/cold
Present
Past
Never
Are your teeth sensitive to biting or chewing?
Present
Past
Never
Are your teeth sensitive to sweets?
Present
Past
Never
If present or past to any, please explain.
Have you ever had orthodontic treatment?
Present
Past
Never
Have you had a bite plate / guard?
Present
Past
Never
Have you had periodontic treatment?
Present
Past
Never
Have you had oral surgery?
Present
Past
Never
Have you had a serious injury to your mouth or head?
Present
Past
Never
If present or past to any, please list what, dates, and reasons.
What is your normal schedule for dental cleanings? (Ex. Every 6 mo)
Date of last dental appointment?
Any complications from dental treatment?
Do you participate in sports?
Submit
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