www.bhasdentistry.com - New Patient Registration

  • Patient Registration

  • Date of Birth*
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  • How did you hear of our office?

  • Spouse/Responsible Party information

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  • Date of Birth
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  • Method of payment or co-payment:
  • Date of Birth
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  • In an emergency, who should be notified?

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  • I certify that I have completed this form fully and completely. The above information is accurate to the best of my knowledge and I understand that providing false information can be dangerous to my health. I grant authority to the Dentist and staff to perform the necessary exam, x-rays, and subsequent treatment needed to restore and maintain my dental health or the health of my dependent.

    I authorize and request my insurance company to pay benefits on my behalf directly to the dentist. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents, including any collection costs.

  • Date*
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  • DENTAL HISTORY

  • How would you rate the condition of your mouth? *
  • How long have you been a patient?*
  • Date of the most recent dental exam
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  • Date of most recent X-rays
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  • Date of most recent treatment (other than a cleaning)
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  • I routinely see my dentist every

  • Please answer "Yes" or "No" to the following

  • PERSONAL HISTORY

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  • Have you had an unfavorable dental experience?*
  • Have you ever had complications from past dental treatment?*
  • Have you ever had trouble getting numb or had any reactions to local anesthetic?*
  • Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?*
  • Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?*

  • GUM AND BONE

  • Do your gums bleed sometimes or are they ever painful when brushing or flossing?*
  • Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?*
  • Have you ever noticed an unpleasant taste or odor in your mouth?*
  • Is there anyone with a history of periodontal disease in your family?*
  • Have you ever experienced gum recession, or can you see more of the roots of your teeth?*
  • Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?*
  • Have you experienced a burning or painful sensation in your mouth not related to your teeth?*

  • TOOTH STRUCTURE

  • Have you had any cavities within the past 3 years?*
  • Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?*
  • Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
  • Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?*
  • Do you have grooves or notches on your teeth near the gum line?*
  • Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?*
  • Do you frequently get food caught between any teeth? *

  • BITE AND JAW JOINT

  • Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)*
  • Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?*
  • Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*
  • In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?*
  • Are your teeth becoming more crooked, crowded, or overlapped?*
  • Are your teeth developing spaces or becoming more loose?*
  • 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?*
  • Do you place your tongue between your teeth or close your teeth against your tongue?*
  • Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*
  • Do you clench or grind your teeth together in the daytime or make them sore?*
  • Do you have any problems with sleep (i.e. Restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?*
  • Do you wear or have you ever worn a bite appliance? *

  • SMILE CHARACTERISTICS

  • Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? *
  • Have you ever bleached (whitened) your teeth?*
  • Have you felt uncomfortable or self conscious about the appearance of your teeth?*
  • Have you been disappointed with the appearance of previous dental work?*
  • Date*
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  • MEDICAL HISTORY

  • What is your estimate of your general health? *

  • Please answer "Yes" or "No" to the following

  • hospitalization for illness or injury*
  • An allergic or bad reaction to any of the following
  • Heart problems, or cardiac stent within the last six months*
  • History of infective endocarditis*
  • Artificial heart valve, repaired heart defect (PFO)*
  • Pacemaker or implantable defibrillator*
  • Orthopedic or soft tissue implant (e.g. joint replacement, breast implant)*
  • Heart murmur, rheumatic or scarlet fever*
  • High or low blood pressure*
  • A stroke (taking blood thinners)*
  • Anemia or other blood disorder*
  • Prolonged bleeding due to a slight cut (or INR> 3.5)*
  • Pneumonia, emphysema, shortness of breath, sarcoidosis*
  • Chronic ear infections, tuberculosis, measles, chicken pox*
  • Breathing problems (e.g. asthma, Stuffy nose, Sinus congestion)*
  • Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bed wetting)*
  • Kidney Disease*
  • Live disease or jaundice *
  • Vertigo (e.g. The room is spinning)*
  • Thyroid, parathyroid disease, or calcium deficiency.*
  • Hormone deficiency or imbalance (e.g. Polycystic ovarian syndrome)*
  • Hormone cholesterol or taking statin drugs*
  • High cholesterol or taking statin) drugs*
  • Diabetes*
  • Stomach or duodenal ulcer*
  • Digestive or eating disorder (e.g. Celiac disease, gastric reflux, bulimia, anorexia)*
  • Osteoporosis/osteopenia or even taken anti-resorptive medications (e.g. Bisphosphonates)*
  • Arthritis or gout*
  • Autoimmune Disease (e.g. rheumatoid arthritis, lupus, scleroderma)*
  • Glaucoma*
  • Contact Lenses*
  • Head or neck injuries*
  • Epilepsy, conclusions (seizures)*
  • Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)*
  • Viral infections and cold sores*
  • Any lumps or swelling in the mouth*
  • Hives, skin rash, hay fever*
  • STI/ STD/ HPV*
  • Hepatitis*
  • HIV/AIDS*
  • Tumor, abnormal growth*
  • Radiation therapy*
  • Chemotherapy, immunosuppressive medication*
  • Emotional difficulties*
  • Psychiatric treatment or antidepressant medication*
  • Concentration problems or ADD/ADHD diagnosis*
  • Alcohol/recreational drug use*

  • ARE YOU

  • Presently being treated for any other illness*
  • Aware of a change in your health in the last 24 hours (e.g. Fever, chills, new cough, or diarrhea)*
  • Taking medication for weight management*
  • Taking dietary supplements, vitamins, and/or probiotics*
  • Often exhausted or fatigues*
  • Experiencing frequent headaches or chronic pain*
  • A smoker, smoked previously or other (smokeless tobacco,vaping, e-cigarettes, and cannabis)*
  • Considered a touch/sensitive person*
  • Often unhappy or depressed*
  • Taking birth control pills
  • Currently Pregnant*
  • Diagnosed with a prostate disorder*
  • Have you taken medications, supplements, vitamins, and/or probiotics in the last two years?*

  • PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATION YOU MAYBE TAKING.

  • Date*
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  • Should be Empty: