• New Patient Registration

  • TODAY'S DATE
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  • DATE OF BIRTH*
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  • Patient Contact Info

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  • Patient Medical History

  • DATE OF LAST EXAM
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  • 1. Are you under medical treatment now?*
  • 2. Have you ever been hospitalized for any surgical operation or serious illness?*
  • 3. Are you taking any medications(s) including non-prescription medicine?*
  • 4. Do you use tobacco?*
  • 5. Do you use alcohol, cocaine or other drugs?*
  • 6. Are you wearing contact lenses?*

  • 7. Are you allergic to or have you had any reactions to the following?

     
  • 7.1 Local anesthetics (eg. novocaine)*
  • 7.2 Barbiturates*
  • 7.3 Aspirin*
  • 7.4 Penicillin or other antibiotics*
  • 7.5 Sedatives*
  • 7.6 Sulfa Drugs*
  • 7.7 Iodine*
  • 8. WOMEN ONLY:
  • 9. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?*

  • 10. Do you have or have you had any of the following?

  • 10.1 High Blood Pressure*
  • 10.2 Heart Attack*
  • 10.3 Rheumatic Fever*
  • 10.4 Swollen Ankles*
  • 10.5 Fainting / Seizures*
  • 10.6 Asthma*
  • 10.7 Low / High Blood Pressure*
  • 10.8 Epilepsy / Convulsions*
  • 10.9 Leukemia*
  • 10.10 Diabetes*
  • 10.11 Kidney Diseases*
  • 10.12 AIDS or HIV Infection*
  • 10.13 Thyroid Problem*
  • 10.14 Heart Disease*
  • 10.15 Cardiac Pacemaker*
  • 10.16 Heart Murmur*
  • 10.17 Angina*
  • 10.18 Anemia*
  • 10.19 Emphysema*
  • 10.20 Cancer*
  • 10.21 Arthritis*
  • 10.22 Joint Replacement or Implant*
  • 10.23 Hepatitis / Jaundice*
  • 10.24 Sexually Transmitted Disease*
  • 10.25 Stomach Troubles / Ulcers*
  • 10.26 Chest Pains*
  • 10.27 Easily Winded*
  • 10.28 Stroke*
  • 10.29 Hay Fever / Allergies*
  • 10.30 Tuberculosis*
  • 10.31 Radiation Therapy*
  • 10.32 Glaucoma*
  • 10.33 Recent Weight Loss*
  • 10.34 Liver Disease*
  • 10.35 Mitral Valve Prolapse*
  • 10.36 Respiratory Problems*

  • Patient Dental History

  • 1. Do your gums bleed while brushing of flossing?*
  • 2.Are your teeth sensitive to hot or cold liquids/foods?*
  • 3. Are your teeth sensitive to sweet or sour liquids/foods?*
  • 4. Do you feel pain to any of your teeth?*
  • 5. Do you have any sores or lumps in or near your mouth?*
  • 6. Have you had any head, neck or jaw injuries?*
  • 7. Have you ever experienced any of the following problem in you jaw?
  • 8. Do you have frequent headaches?*
  • 9. Do you clench or grind your teeth?*
  • 10. Do you bite your lips or cheeks frequently?*
  • 11. Have you ever had any difficult extractions in the past?*
  • 12. Have you ever had any orthodontic treatment?*
  • 13. Have you ever had prolonged bleeding following extractions?*
  • 14. Have you ever had instruction on the correct method of brushing your teeth ?*
  • 15. Have you ever had instruction on the care of your gums?*
  • DATE
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