ABC HEALTH HISTORY & REGISTRATION

Form
PATIENT INFORMATION
Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Date
Age
Sex

MaleFemale
Social Security Number
xxx-xx-xxxx
If patient is a minor, give parent or guardians name:
Todays Date

MonthDayYear
Date
Who may we thank for referring you to our office?
Reason for this visit
RESPONSIBLE PARTY INFORMATION
Name

First NameMiddle InitialLast Name
Marital Status
Residence

Street Address

Apt #

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Apt #

CityState / Province

Postal / Zip Code
How long at this address
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Social Security Number
xxx-xx-xxxx
Birthdate

MonthDayYear
Date
Drivers License Number
Relation to Patient
Employer
Occupation
Years Employed
RESPONSIBLE PARTY'S SPOUSE
Name

First NameMiddle NameLast Name
Employer
Occupation
Years Employed
Social Security Number
Birthdate

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Email
example@example.com
EMERGENCY INFORMATION: RELATIVE NOT LIVING WITH YOU
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
DENTAL INSURANCE INFORMATION (Primary Carrier)
Insured's Name

First NameLast Name
Insurance Company
Email
example@example.com
Insurance Company Address
Insured's Employer
Insured's Social Security Number
IF YOU HAVE DUAL INSURANCE COVERAGE: COMPLETE THE FOLLOWING FOR THE SECOND COVERAGE:
Insured's Name

First NameLast Name
Insurance Company
Email
example@example.com
Insurance Company Address
Insured's Employer
Insured's Social Security Number
DENTAL HISTORY
How long since you have seen a dentist?
Last COMPLETE dental exam date

MonthDayYear
Date
Last full mouth x-ray date

MonthDayYear
Date
Are you having problems now?

YesNo
What?
Is your present dental health poor?

YesNo
Do you wear dentures?

YesNo
Are you unhappy with your dentures?

YesNo
Would you like to know about permanent replacements?

YesNo
Are you apprehensive about dental treatment?

YesNo
Have you had any periodontal (gum) treatments?

YesNo
Do your gums bleed, or feel tender or irritated?

YesNo
Are your teeth sensitive to:

HotColdSweetsPressureNone
Are you happy with the appearance of your teeth?

YesNo
Are you aware of grinding or clenching your teeth?

YesNo
Do you have headaches, earaches, or neck pains?

YesNo
Have you worn braces on your teeth?

YesNo
Do you have discolored teeth that bother you?

YesNo
Would you like to look better or different?

YesNo
Do you regularly use dental floss?

YesNo
Name of previous dentist
Where?

CityState
Please RANK the following based on the order in which they would KEEP YOU from having dental treatment:
Fear of pain #blanks
Lack of concern # blank
Cost of treatment # Type a label
Missing work time Type a label
Do you have any current health problems?

YesNo
Are you under a physician's care right now?

YesNo
If so, for what?
What medications are you currently taking?
Have you ever taken Fen-Phen/Redux?

YesNo
Have you ever used a biophosphonate medication? (Brand names include: Fosamax, Atelvia, Didronel, and Boniva)

YesNo
Are you pregnant?

YesNo
Do you use:

Cigars/CigarettesPipeChewing TobaccoNone
Please check all of the following which you have had, or presently have:

AIDS/HIV PositiveAnaphylaxisAnemiaArthritis (Rheumatism)Artificial heart valvesArtificial JointsAsthmaAtopic (Allergy Prone)Back ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough (persistent)Cough Up BloodDiabetesEpilepsyFaintingFood AllergiesGlaucomaHeadachesHeart MurmurHeart ProblemsHemophilia (Abnormal bleeding)HerpesHepatitisHigh Blood PressureJaw PainKidney Disease or MalfunctionLiver DiseaseMaterial Allergies (latex, wool, metals, chemicals)Mitral Valve ProlapseNervous ProblemsPacemaker/Heart SurgeryPsychiatric CareRapid weight gain/lossRadiation TreatmentRespiratory DiseaseRheumatic/Scarlet FeverShinglesSkin RashShortness of BreathSpina BifidaStrokeSurgical ImplantSwelling of Feet or AnklesThyroid Disease or MalfunctionTobacco HabitTonsilitisTuberculosisUlcer/ColitisVenereal Disease
Are you allergic to or have you reacted adversely to the following medications?

AspirinLocal AnestheticErythromycinLatex (balloons, gloves, etc.)Nitrous OxideCodeinePenicillinOther
Is there any other Medical or Dental information that you feel I should know about you?
Family Physician:
Family Physician Phone
Please enter a valid phone number.
Family Physician Email
example@example.com
Patient Signature (Parent of Child)

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