Patient Reg Form

Health History
To our patients:

Although dentists primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Patient Name

First NameLast Name
Reason for today's office visit?
1. Height
Weight
Are you in good health?
2. Have there been any changes in your general health in the past year?
3. Are you under the care of a physician?
Date of last visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
If so, for what are you being treated?
4. Have you had any illness, operation or been hospitalized in the past five years?
If so, describe
5. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
If so, describe where
6. Do you have a prosthetic joint / implant?
If so, describe where
7. Have you had a heart valve replacement or vascular graft?
8. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Have you had, or do you currently have:

Rows	Yes	No
9. Rheumatic fever?
10. Damaged heart valves / mitral valve prolapse?
11. Heart murmur?
12. High blood pressure?
13. Low blood pressure?
14. Chest pain / angina?
15. Heart attack(s)?
16. Irregular heart beat?
17. Cardiac pacemaker?
18. Heart surgery?
19. Pneumonia, bronchitis, chronic cough?
20. Asthma?
21. Hay fever / sinus problems?
22. Snoring?
23. Sleep apnea / CPAP?
24. Difficult breathing / other lung trouble?
25. Tuberculosis?
26. Emphysema?
27. Do you smoke or vape?
28. Do you use chewing tobacco?
29. Blood transfusion?
30. Blood disorder such as anemia?
31. Bruise easily?
32. Bleeding tendency / abnormal bleed?
33. Hepatitis, jaundice, or liver disease?
34. Infectious mononucleosis?
35. Gallbladder trouble?

Have you had, or do you currently have:

Rows	Yes	No
36. Fainting spells?
37. Convulsions / epilepsy?
38. Stroke?
39. Thyroid trouble?
40. Diabetes?
41. Low blood sugar?
42. Kidney trouble?
43. High cholesterol?
44. Are you on dialysis?
45. Swollen ankles / arthritis / joint disease?
46. Osteoporosis / osteopenia?
47. Osteonecrosis?
48. Stomach ulcer / acid reflux?
49. Contagious diseases?
50. Sexually transmitted diseases?
51. Problems with immune system? Possibly from medication / surgery, etc.
52. Delay in healing?
53. A tumor or growth?
54. Cancer / radiation therapy / chemotherapy?
55. Chronic fatigue / night sweats?
56. Are you on a diet?
57. A history of alcohol abuse?
58. A history of marijuana or other drug use?
59. Contact lenses?
60. Eye disease / glaucoma?
61. Mental health problems / anxiety / depression?
62. A removable dental appliance?
63. Pain or clicking of jaws when eating?

Women Only

(QUESTIONS 64-67)
64. Is there a possibility of pregnancy?
65. Expected delivery date?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
66. Are you nursing?
67. Are you taking birth control pills?
Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

ARE YOU NOW TAKING:

Rows	Yes	No
68. Any kind of medication, drug, pills?
69. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Xarelto, Eliquis, Fish oil)?
70. Have you ever taken diet pills?
71. Any natural product, herbal supplement or homeopathic remedy?
72. Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years?

73. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?
If so, please list:
74. If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:
Treating doctor:
75. Please list any medications you are currently taking:
Is there any condition concerning your health that the Doctor should be told about?
If Yes, describe
Do you wish to speak to the Doctor privately about anything?

ARE YOU ALLERGIC TO, OR HAD A REACTION TO:

Rows	Yes	No
76. Local anesthetic (numbing meds.)?
77. Penicillin?
78. Other antibiotics?
79. Sulfa Drugs?
80. Sodium pentothal / Valium /other tranquilizers?
81. Aspirin?
82. Amoxicillin?
83. Codeine or other narcotics?
84. Latex?
85. Sulfites?
86. Do you have any known allergies?

86. Please list any allergies other than drug allergies:
86. Please list any other medication or antibiotic you are allergic to:
87. Is there a family history of:
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
Signature of patient (Parent or Guardian if Minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Reviewed by
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please verify that you are human
Should be Empty: