• MEDICAL HISTORY & PATIENT REGISTRATION

    MEDICAL HISTORY & PATIENT REGISTRATION

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION:

    If you do not have insurance write N/A in the sections below:
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  • GENERAL HEALTH QUESTIONNAIRE

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  • Are you under the care of a physician?*
  • Have you had any serious illness or operation?*
  • Are you taking any medications?*
  • Are you taking Aspirin?*
  • Are you taking Anticoagulants/Blood Thinner?*
  • Are you taking Blood Pressure Medicine?*
  • Are you taking Antidepressants/Tranquilizers?*
  • Are you taking Cortisone (steroids)?*
  • Are you taking Heart Medications?*
  • Are you taking Insulin?*
  • Are you taking Nitroglycerin?*
  • Do you have or have you had AIDS, ARC, HIV+ ?*
  • Do you have or have you had Arthritis?*
  • Do you have or have you had Artificial Heart Valves?*
  • Do you have or have you had Asthma?*
  • Do you have or have you had Cancer/Chemotherapy?*
  • Do you have or have you had Diabetes?*
  • Do you have or have you had Difficulty Breathing?*
  • Do you have or have you had Epilepsy/Seizures?*
  • Do you have or have you had Excessive Bleeding or Clotting Problems?*
  • Do you have or have you had GI disorders/Procedures?*
  • Do you have or have you had Heart Disease or Attack / M.V.P. ?*
  • Do you have or have you had Hepatitis/Liver Disease?*
  • Do you have or have you had High Blood Pressure?*
  • Do you have or have you had Kidney Disease?*
  • Do you have or have you had Pacemaker?*
  • Do you have or have you had Prosthetic Hip or Joint?*
  • Do you have or have you had Psychiatric Treatment?*
  • Do you have or have you had Rheumatic Fever/Heart Murmur?*
  • Do you have or have you had Sinus Problems?*
  • Do you have or have you had Stomach Ulcers?*
  • Do you have or have you had Stroke?*
  • Do you have or have you had Thyroid?*
  • Do you have or have you had Tuberculosis or other Lung Disease?*
  • Do you have or have you had Venereal Disease?*
  • Are you allergic or have you reacted adversely to Aspirin?*
  • Are you allergic or have you reacted adversely to Codeine or other Narcotic?*
  • Are you allergic or have you reacted adversely to Erythromycin?*
  • Are you allergic or have you reacted adversely to Latex?*
  • Are you allergic or have you reacted adversely to Local Anesthetics?*
  • Are you allergic or have you reacted adversely to Penicillin or other Antibiotics?*
  • Are you allergic or have you reacted adversely to Tetracycline?*
  • Note: if does not apply type N/A in the sections below.

  • Dental History

  • Have you had problems with your teeth?*
  • Is your teeth sensitive to any of the below*
  • Do your gums bleed easily?*
  • Have you noticed any loose teeth?*
  • Do you brush daily?*
  • Do you floss regularly?*
  • Have you ever had your teeth straightened?*
  • Do you grind or clench your teeth ever?*
  • Do you get oral herpes/fever blisters?*
  • Do you use tobacco products?*
  • If yes, what kind?
  • Do you have TMJ/TMD joint pain?*
  • Do you use nitrous oxide or laughing gas in dental treatment?*
  • Do you have any fillings that feel rough or areas where food collects?*
  • Have you ever had or been advised to have gum/ periodontal therapy?*
  • Are you happy with the way your smile looks?*
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  • Should be Empty: