Patient Registration

Adenoids Removed

YesNo

When

Sore Throat

YesNo

Tonsillitis

YesNo

Earaches

YesNo

AIDS or HIV

YesNo

Asthma

YesNo

Endocrine Problems

YesNo

Pneumonia

YesNo

Nervous Disorders

YesNo

High Blood Pressure

YesNo

Hearing Disorder

YesNo

Major/Minor Surgery

YesNo

Type/Date

Has patient reached puberty (girl - started menstruation, boy - has his voice changed)?

YesNo

List any serious illnesses

Please list all medications, over the counter and herbal supplements that you take

Have any members of your family had:

Rheumatoid Arthritis

YesNo

Dental History - please answer if patient has or has had the following:

Any injuries to face, mouth or teeth

YesNo

Thumb, finger or lip sucking

YesNo

More than average amount of tooth decay

YesNo

Missing permanent teeth

YesNo

Extra permanent teeth

YesNo

Teeth removing by extraction

YesNo

Difficulty in swallowing or chewing

YesNo

Tongue thrust problem

YesNo

Mouth breathing when asleep

YesNo

Mouth breathing when awake

YesNo

Pain or clicking when opening mouth

YesNo

Clenching or grinding of teeth

YesNo

Frequent headaches

YesNo

Headaches per week/time of day

Muscle tenderness or stiffness in the jaw or neck

YesNo

Please enter the insured party details

First Name

First NameMiddle InitialLast Name

Relationship to patient

Birthdate

Date

Insured ID

Please enter the employer details

Name

Contact

Phone - Ext

Area CodePhone Number

Fax

Group Number

Policy Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code