Kondorossy Dental Art & Implant Center New Patient Registration with Dental Hygiene

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? Don't Know

Are you now under the care of a physician? *

Yes No

Physician Name

First Name Last Name

Physician Phone Number

Area Code Phone Number

Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Are you in good health? *

Yes No

Have there been any changes in your health in the past year? *

Yes No

Please explain these changes below:

Date of last physical exam?

Have you been hospitalized in the past 5 years? *

Yes No Don't Know

What was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)? *

Yes No Don't Know

Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken. This includes vitamins, natural, or herbal preparations and/or dietary supplements.

Do you wear contact lenses? *

Yes No Don't Know

Do you use controlled substances (drugs)? *

Yes No Don't Know

Do you use tobacco (smoking, snuff, chew, bidis)? *

Yes No Don't Know

How interested are you in stopping? *

Very Somewhat Not Interested

Do you drink alcohol? *

Yes No

If yes, how many drinks in last 24 hours? How many per week? *

Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement? *

Yes No

Please include date, type of replacement and any complications below: *

Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)? *

Yes No

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

Please include what type, dosage and when was it taken? *

For which condition? *

Bone pain Paget’s disease Multiple myeloma Metastatic cancer

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?

If yes to any please specify type and reaction. *

Please indicate if you have or have had any of the following diseases or problems.

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

Bite nails? *

Present Past Never

Suck your thumb/finger? *

Present Past Never

Use a toothpick or stimulator? *

Present Past Never

Use chewing gum? *

Present Past Never

Eat candy? *

Present Past Never

Drink soft drinks? *

Present Past Never

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

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

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? *

New Patient Registration

Emergency Contact Info

Medical Information

Medical History