PATIENT REGISTRATIONFirst NameLast NameMIPatient Is Policy Holder Responsible Party Preferred Name:Responsible Party (If someone other than the patient)First NameLast NameMIAddressCity, State, ZipHome PhoneWork PhoneCellBirth Date Soc. SecDrivers LicResponsible Party Policy Holder Responsible party is also Policy Holder for Patient Secondary Ins. Policy Holder Patient InformationAddressCity, State, ZipHome PhoneWork PhoneCellBirth Date Soc. SecDrivers LicSex Male Female Marital Status Married Single Divorced Separated Widowed E-MailCorrespondences I would like to receive correspondences via e-mail Employment Status Full Time Part Time Retired Student Status Full Time Part Time Primary Insurance InformationName of InsuredRelationship to Insured Self Spouse Child Other Insured Soc. SecInsured Date of Birth EmployerInsurance CompanyAddressAddressCity, State, ZipCity, State, ZipGroup #ID #Secondary Insurance InformationName of InsuredRelationship to Insured Self Spouse Child Other Insured Soc. SecInsured Date of Birth EmployerInsurance CompanyAddressAddressCity, State, ZipCity, State, ZipGroup #ID #MEDICAL HISTORYPatient NameNicknameAgeName of Physician/and their specialtyMost recent physical examinationPurposeWhat is your estimate of your general health? Excelent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD:1. hospitalization for illness or injury Yes No 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) iodine metals (nickel, gold, silver) latex nuts fruit milk red dye other 3. heart problems, or cardiac stent within the last six months Yes No 4. history of infective endocarditis Yes No 5. artificial heart valve, repaired heart defect (PFO) Yes No 6. peacemaker or implantable defibrillator Yes No 7. orthopedic or soft tissue implant (e.g., joint replacement, breast implant) Yes No 8. heart murmur, rheumatic or scarlet fever Yes No 9. high or low blood pressure Yes No 10. a stroke (taking blood thinners) Yes No 11. anemia or other blood disorder Yes No 12. prolonged bleeding due to a slight cut (or INR > 3.5) Yes No 13. pneumonia, emphysema, shortness of breath, sarcoidosis Yes No 14. chronic ear infections, tuberculosis, measles, chicken pox Yes No 15. breathing problems (e.g., asthma, nasal breathing, stufy nose, sinus congestion) Yes No 16. sleep problems (e.g., sleep apnea, snoring, insomnia, restless sleep, bedwetting) Yes No 17. kidney disease Yes No 18. liver disease or jaundice Yes No 19. vertigo (e.g., "the room is spinning") Yes No 20. thyroid, parathyroid disease, or calcium deficiency Yes No 21. hormone deficiency or imbalance (e.g., polycystic ovarian syndrome) Yes No 22. high cholesterol or taking statin drugs Yes No 23. diabetes (HbA1c=_____) Yes No 24. stomach or duodental ulcer Yes No 25. digestive or eating disorders (e.g., gastric reflux, bulimia, anorexia, cellac disease, Crohn's disease, or any inflammatory bowel disease) Yes No 26. osteoporosis/osteopenia or even taken anti-resorptive medications (e.g., bisphosphonates) Yes No 27. arthritis or gout Yes No 28. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma) Yes No 29. glaucoma Yes No 30. contact lenses Yes No 31. head or neck injuries Yes No 32. epilepsy, convulsions (seizures) Yes No 33. neurologic disorders (e.g., Alzheimer's disease, dementia, prion disease) Yes No 34. viral infections (e.g., cold sores) bacterial infections (e.g., Lyme disease) Yes No 35. any lumps or swelling in the mouth Yes No 36. hives, skin rash, hay fever Yes No 37. STI/STD/HPV Yes No 38. hepatitis (type___) Yes No 39. HIV/AIDS Yes No 40. tumor, abnormal growth Yes No 41. radiation therapy Yes No 42. chemotherapy, immunosuppressive medication Yes No 43. difficulties with stress management Yes No 44. psychiatric treatment, antidepressants, mood stabilizing medications Yes No 45. concentration problems or ADD/ADHD Yes No 46. alcohol/recreational drug use Yes No ARE YOU:47. presently being treated for any other illness Yes No 48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea) Yes No 49. taking medication for weight management Yes No 50. taking dietary supplements, vitamins, and/or probiotics Yes No 51. often exhausted or fatigued Yes No 52. experiencing frequent headaches or chronic pain Yes No 53. a smoker, smoked previously or other (e.g., smokeless tobacco, vaping, e-cigarettes, and cannabis) Yes No 54. considered a touchy/sensitive person Yes No 55. often unhappy or depressed Yes No 56. taking birth control pills Yes No 57. currently pregnant Yes No 58. diagnosed with a prostate disorder Yes No Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, vitamins, and/or probiotics taken within the last two years.PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Patient's SignatureDate Doctor's SignatureDate DENTAL HISTORYPatient NameNicknameAgeReferred byHow would you rate the condition of your mouth? Excellent Good Fair Poor Previous DentistHow long have you been a patient? (Months/Years)Date of most recent dental exam Date of most recent x-rays Date of most recent treatment (other than a cleaning) I routinely see my dentist every 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN?PLEASE ANSWER YES OR NO TO THE FOLLOWING:PERSONAL HISTORY1. Are you fearful of dental treatment? How fearful, on a scale of 1(least) to 10(most)2. Have you had an unfavorable dental experience? Yes No 3. Have you ever had complications from past dental treatment? Yes No 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes No 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and what age?6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No GUM AND BONE7. Do your gums bleed sometimes or are they ever painful when brushing or flossing? Yes No 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No 9. Have you ever noticed an unpleasant taste or odor in your mouth? Yes No 10. Is there anyone with a history of periodontal disease in your family? Yes No 11. Have you ever experienced gum recession, or can you see more of the roots of your teeth? Yes No 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes No TOOTH STRUCTURE14. Have you had any cavities within the past 3 years? Yes No 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? Yes No 18. Do you have grooves or notches on your teeth near the gum line? Yes No 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No 20. Do you frequently get food caught between any teeth? Yes No BITE AND JAW POINT21. Do you have problems with your jaw point? (pain, sounds, limited opening, locking, popping) Yes No 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? Yes No 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes No 25. Are your teeth becoming more crooked, crowded, or overlapped? Yes No 26. Are your teeth developing spaces or becoming more loose? Yes No 27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes No 28. Do you place your tongue between your teeth or close your teeth against your tongue? Yes No 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No 30. Do you clench or grind your teeth together in the daytime or make them sore? Yes No 31. Do you have any problem with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? Yes No 32. Do you wear or have you ever worn a bite appliance? Yes No SMILE CHARACTERISTICS33. Is there anything about the appearance of your mouth (smile, lips,teeth, gums) that you would like to change (shape, color, size, display)? Yes No 34. Have you ever whitened (bleached) your teeth? Yes No 35. Have you felt uncomfortable or self conscious about the appearance of you teeth? Yes No 36. Have you been disappointed with the appearance of your previous dental work? Yes No Patient's SignatureDate Doctor's SignatureDate CAPTCHA
