Patient Reg Form

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

YesNo

Date of last visit

If so, for what are you being treated?

YesNo

If so, describe

YesNo

If so, describe where

YesNo

If so, describe where

YesNo

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?

YesNo

65. Expected delivery date?

YesNo

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?

YesNo

If so, please list:*

Treating doctor:*

YesN/A

YesNo

If Yes, describe

YesNo

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:

CancerDiabetesHeart diseaseAnesthesia problems

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*

Reviewed by

Date

Please verify that you are human*

Health History

Women Only