MDC Patient Registration

PATIENT REGISTRATION
PATIENT ACCOUNT NUMBER*
PATIENT'S LAST NAME*
PATIENT'S FIRST NAME*
M. INITIAL*
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*

STREET ADDRESS

Street Address Line 2

CITY, STATE & ZIPState / Province

Postal / Zip Code
SEX*

MALEFEMALE
DRIVERS LICENSE NO.*
HOME PHONE NUMBER
Please enter a valid phone number.
WORK PHONE ADDRESS
Please enter a valid phone number.
CELL PHONE NUMBER
Please enter a valid phone number.
Do you receive text messages on your cell?*

YESNO
EMAIL ADDRESS*
example@example.com
EMPLOYED BY*
MARITAL STATUS*

SINGLEMARRIEDSEPARATEDDIVORCEDWIDOWED
BUSINESS ADDRESS*
WHO WILL PAY THIS ACCOUNT*
(whose name is to appear on billing statement?)
EMERGENCY CONTACT ADDRESS & PHONE*
(not at same address)
WHOM MAY WE THANK FOR REFERRING YOU?*

YELLOW PAGESINTERNETFRIENDS/FAMILYOther
SPOUSE'S LAST NAME
FIRST NAME
M. INITIAL
DATE OF BIRTH

MonthDayYear
Date
ADDRESS

STREET ADDRESS

Street Address Line 2

CITY, STATE & ZIPState / Province

Postal / Zip Code
HOME PHONE
EMAIL ADDRESS
example@example.com
DRIVERS LICENSE NO.
WORK PHONE
EMPLOYED BY
MARITAL STATUS

SINGLEMARRIEDSEPARATEDDIVORCEDWIDOWED
CELL PHONE
BUSINESS ADDRESS
HOW LONG EMPLOYED
WAGE

HOURLYSALARYRETIRED
PRIMARY DENTAL INSURANCE CO.*
MAILING ADDRESS*
GROUP #*
SERVICE CODE*
CONTRACT ID*
INS. CO. PHONE NO.*
SECONDARY DENTAL INSURANCE CO.
MAILING ADDRESS
GROUP #
SERVICE CODE
CONTRACT ID
INS. CO. PHONE NO.
MEDICAL INS NAME*

Blue CrossMedicareOther
GROUP NO.*
SUBSCRIBER NAME & DATE OF BIRTH*
SERVICE CODE*
Patient Name*
Date of Birth*

MonthDayYear
Date
I. CIRCLE APPROPRIATE ANSWER
Is your general health good?*

YESNO
Has there been a change in your health within the last year?*

YESNO
Have you been hospitalized or had a serious illness in the last three years?*

YESNO
If YES, explain?
Are you being treated by a physician now?*

YESNO
Are you being treated by a physician now? For what?
Physician's Name and Phone No.
Date of last Dental Exam

MonthDayYear
Date
Are you in pain now?*

YESNO
Are you in pain now? If YES, please explain
II. DO YOU HAVE OR HAVE YOU HAD: (If yes, please indicate by circling appropriate answer)
Heart disease, heart attack, pacemaker, prosthetic heart valve, or heart murmur?*

YESNO
If YES, please explain
Treating Physician's Name & Phone No
Rheumatic fever?*

YESNO
Stroke, hardening of arteries?*

YESNO
High blood pressure?*

YESNO
Asthma, TB, emphysema, other lung disease?*

YESNO
Hepatitis, other liver disease?*

YESNO
Diabetes*

YESNO
Psychiatric care?*

YESNO
Tumors, cancer?*

YESNO
Radiation treatments or Chemotherapy?*

YESNO
Arthritis, rheumatism*

YESNO
Artificial joint?*

YESNO
Osteoporosis?*

YESNO
Blood transfusions?*

YESNO
HIV/AIDS?*

YESNO
Thyroid, adrenal disease?*

YESNO
Kidney, bladder disease?*

YESNO
Herpes?*

YESNO
VD (syphilis/gonorrhea)?*

YESNO
Anemia?*

YESNO
Allergies to: drugs, food, medications, latex, nickel.*

YESNO
If YES please list:
II. DO YOU HAVE OR HAVE YOU HAD: (If yes, please indicate by circling appropriate answer)
Tobacco in any forms?*

YESNO
If Yes, how much
Alcohol?*

YESNO
If Yes, how much
Drugs, medications, over-the-counter medicines (including aspirin), natural remedies?*

YESNO
Please list:
Recreational Drugs?*

YESNO
IV. WOMEN ONLY:
Are you or could you be pregnant or nursing?

YESNO
Taking birth control pills?

YESNO
IV. ALL PATIENTS:
Is there anything else you think we should be aware of?*

YESNO
If Yes, please explain:
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Patient Signature*

Clear
Date*

MonthDayYear
Date
HEADACHE AND FACIAL PAIN SCREENING QUESTIONNAIRE
Name*
Date*

MonthDayYear
Date
Temporomandibular Disorders are a frequent cause of headaches, facial pain and dental pain. Please complete this screening questionnaire.

SYMPTOM CHECKLIST: Please check any of the following symptoms that apply to you. (L-left and R-right)
Headaches:

MigrainesTension HeadachesOther
How often:
Top of Head

LeftRight
Temples

LeftRight
Forehead

LeftRight
Behind Eyes

LeftRight
Back of Head

LeftRight
Pain in Shoulder

LeftRight
Pain in Head

LeftRight
Ear Congestion

LeftRight
Pain in Ear:

LeftRight
Tinnitus (ringing in ears)

LeftRight
Dizziness (vertigo)

LeftRight
Facial Pain (non-specific)

LeftRight
Dizziness (vertigo)

LeftRight
Grating sound in joint

LeftRight
Clicking or popping in jaw joint

LeftRight
Partial inability to open mouth

NoYesConstantSporadic
Face muscle twitch

NoYes
Difficulty swallowing

NoYes
Difficulty breathing through nose

NoYes
Difficulty chewing

NoYes
Have you ever worn braces

NoYes
Age when braces were on
Orthodontist
SLEEP APNEA EVALUATION
We have seen a recent increase of sleep apnea findings in our patients, which is a life threatening medical problem. To protect your health, we are asking you to complete the following screening form.

Please answer:
BMI*
(dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a conversion factor of 703)
Do you snore?*

NoYes
Are you excessively tired during the day?*

NoYes
Have you been told you stop breathing during sleep?*

NoYes
Do you have a history of hypertension?*

NoYes
Is your neck size greater than... (17 inches - male | 16 inches female)*

NoYes
YES to two or more of these questions is a positive screen for sleep apnea. If you answered yes to two or more questions, show this completed questionnaire to your doctor.
Should be Empty:

PATIENT REGISTRATION

I. CIRCLE APPROPRIATE ANSWER

II. DO YOU HAVE OR HAVE YOU HAD: (If yes, please indicate by circling appropriate answer)

II. DO YOU HAVE OR HAVE YOU HAD: (If yes, please indicate by circling appropriate answer)

IV. WOMEN ONLY:

IV. ALL PATIENTS:

HEADACHE AND FACIAL PAIN SCREENING QUESTIONNAIRE

SLEEP APNEA EVALUATION