New Patient Registration
Berson Dental Health Care
Today's Date
-
Month
-
Day
Year
Email
example@example.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Business/Cell Phone Number
-
Area Code
Phone Number
Weight
*
Height
*
Date of Birth
*
-
Month
-
Day
Year
Occupation
*
Sex
*
Male
Female
Other
SS# or Patient ID
If you are completing this form for another person, what is your relationship to that person?
Your Name
First Name
Last Name
Relationship to Patient
Emergency Contact Info
Name
*
First Name
Last Name
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Relationship to Patient
*
Medical Information
Current Dentist Name
First Name
Last Name
Current Dentist Phone Number
-
Area Code
Phone Number
Date of last X-Rays
Back
Next
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?
Don't Know
Are you now under the care of a physician?
*
Yes
No
Don't Know
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
Are you in good health?
*
Yes
No
Don't Know
Have there been any changes in your health in the past year?
*
Yes
No
Don't Know
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
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?
*
Yes
No
Don't Know
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
Don't Know
Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?
*
Yes
No
Don't Know
For which condition?
*
Bone pain
Paget’s disease
Multiple myeloma
Metastatic cancer
Other
What type, dosage and when was it taken?
*
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
Don't Know
If yes, how many drinks in last 24 hours? How many per week?
*
Please include what type, dosage and when was it taken?
*
WOMEN ONLY Are you?
*
Rows
Yes
No
Don't Know
Pregnant?
Taking birth control pills or hormonal replacement?
Nursing?
Allergies. Are you allergic to or had a reaction to the following:
*
Rows
Yes
No
Don't Know
Local anesthetics
Aspirin
Penicillin or other antibiotiics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay feveer
Animals
Food
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
None of the above
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?
*
Dental Information
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?
*
Do your gums bleed when you brush or floss?
*
Yes
No
Don't Know
Is your mouth dry?
*
Yes
No
Don't Know
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
Is your home water supply fluoridated?
*
Present
Past
Never
Do you drink bottled or filtered water?
*
Yes
No
Don't Know
Have you ever had orthodontic (braces) treatment?
*
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
Do you have earaches or neck pain?
*
Yes
No
Don't Know
Do you have clicking, popping or discomfort in the jaw?
*
Yes
No
Don't Know
Do you have sores or ulcers in your mouth?
*
Yes
No
Don't Know
Do you wear dentures or partials?
*
Yes
No
Don't Know
Have you had oral surgery?
*
Present
Past
Never
Have you had a serious injury to your mouth or head?
*
Present
Past
Never
Have you had any problems associated with previous dental treatment?
*
Yes
No
How do you feel about your smile?
*
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?
*
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