MEDICAL HISTORY & PATIENT REGISTRATION
Name
*
First Name
Last Name
S.S. No
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Height
Weight
Marital status
Occupation
Employer Name
INSURANCE INFORMATION:
If you do not have insurance write N/A in the sections below:
Dental Insurance
*
Policyholder Name
*
ID Number
*
Insurance Phone Number
*
Spouse/Guardian Name
S.S. No
Birthdate
-
Month
-
Day
Year
Date
Occupation
Employer Name
Referred By (We like to say “Thank You”)
Emergency Contact
GENERAL HEALTH QUESTIONNAIRE
My last physical examination was on
*
-
Month
-
Day
Year
Date
Are you under the care of a physician?
*
Yes
No
If yes, what is the condition being treated? Note: if you do not have a condition type N/A in the section below.
*
Name and phone number of physician
*
Have you had any serious illness or operation?
*
Yes
No
If yes, what was the illness or operation?
*
Are you taking any medications?
*
Yes
No
If yes, what?
Are you taking Aspirin?
*
Yes
No
Are you taking Anticoagulants/Blood Thinner?
*
Yes
No
Are you taking Blood Pressure Medicine?
*
Yes
No
Are you taking Antidepressants/Tranquilizers?
*
Yes
No
Are you taking Cortisone (steroids)?
*
Yes
No
Are you taking Heart Medications?
*
Yes
No
Are you taking Insulin?
*
Yes
No
Are you taking Nitroglycerin?
*
Yes
No
Do you have or have you had AIDS, ARC, HIV+ ?
*
Yes
No
Do you have or have you had Arthritis?
*
Yes
No
Do you have or have you had Artificial Heart Valves?
*
Yes
No
Do you have or have you had Asthma?
*
Yes
No
Do you have or have you had Cancer/Chemotherapy?
*
Yes
No
Do you have or have you had Diabetes?
*
Yes
No
Do you have or have you had Difficulty Breathing?
*
Yes
No
Do you have or have you had Epilepsy/Seizures?
*
Yes
No
Do you have or have you had Excessive Bleeding or Clotting Problems?
*
Yes
No
Do you have or have you had GI disorders/Procedures?
*
Yes
No
Do you have or have you had Heart Disease or Attack / M.V.P. ?
*
Yes
No
Do you have or have you had Hepatitis/Liver Disease?
*
Yes
No
Do you have or have you had High Blood Pressure?
*
Yes
No
Do you have or have you had Kidney Disease?
*
Yes
No
Do you have or have you had Pacemaker?
*
Yes
No
Do you have or have you had Prosthetic Hip or Joint?
*
Yes
No
Do you have or have you had Psychiatric Treatment?
*
Yes
No
Do you have or have you had Rheumatic Fever/Heart Murmur?
*
Yes
No
Do you have or have you had Sinus Problems?
*
Yes
No
Do you have or have you had Stomach Ulcers?
*
Yes
No
Do you have or have you had Stroke?
*
Yes
No
Do you have or have you had Thyroid?
*
Yes
No
Do you have or have you had Tuberculosis or other Lung Disease?
*
Yes
No
Do you have or have you had Venereal Disease?
*
Yes
No
Are you allergic or have you reacted adversely to Aspirin?
*
Yes
No
Are you allergic or have you reacted adversely to Codeine or other Narcotic?
*
Yes
No
Are you allergic or have you reacted adversely to Erythromycin?
*
Yes
No
Are you allergic or have you reacted adversely to Latex?
*
Yes
No
Are you allergic or have you reacted adversely to Local Anesthetics?
*
Yes
No
Are you allergic or have you reacted adversely to Penicillin or other Antibiotics?
*
Yes
No
Are you allergic or have you reacted adversely to Tetracycline?
*
Yes
No
Note: if does not apply type N/A in the sections below.
Do you take birth control pills?
*
Are you breastfeeding or pregnant?
*
If yes, what is your due date?
Dental History
When did you have your last dental exam?
*
Dentist name and address
*
Have you had problems with your teeth?
*
Yes
No
If yes, what kind?
Is your teeth sensitive to any of the below
*
Cold
Hot
Both
None
If yes, which one and where?
Do your gums bleed easily?
*
Yes
No
Have you noticed any loose teeth?
*
Yes
No
Do you brush daily?
*
Yes
No
Do you floss regularly?
*
Yes
No
Have you ever had your teeth straightened?
*
Yes
No
Do you grind or clench your teeth ever?
*
Yes
No
Do you get oral herpes/fever blisters?
*
Yes
No
Do you use tobacco products?
*
Yes
No
If yes, what kind?
Chew
Cigar
Cigarette
Pipe
Do you have TMJ/TMD joint pain?
*
Yes
No
Do you use nitrous oxide or laughing gas in dental treatment?
*
Yes
No
Do you have any fillings that feel rough or areas where food collects?
*
Yes
No
If yes, where?
Have you ever had or been advised to have gum/ periodontal therapy?
*
Yes
No
If yes, when?
Are you happy with the way your smile looks?
*
Yes
No
If not, what would you change?
Patient or Guardian Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform