• PATIENT REGISTRATION

  • DATE OF BIRTH*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • SEX*
  • Do you receive text messages on your cell?*
  • MARITAL STATUS*
  • Date OF BIRTH
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • MARTIAL STATUS
  • Date OF BIRTH
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • MARTIAL STATUS
  • Format: (000) 000-0000.
  • WHOM MAY WE THANK FOR REFERRING YOU?*
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I. CIRCLE APPROPRIATE ANSWER

  • Is your general health good?*
  • Has there been a change in your health within the last year?*
  • Have you been hospitalized or had a serious illness in the last three years?*
  • Are you being treated by a physician now?*
  • Date of last Dental Exam*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you in pain now?*

  • 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?*
  • Rheumatic fever?*
  • Anemia?*
  • Stroke, hardening of arteries?*
  • VD (syphilis/gonorrhea)?*
  • High blood pressure?*
  • Herpes?*
  • Asthma, TB, emphysema, other lung disease?*
  • Kidney, bladder disease?*
  • Hepatitis, other liver disease?*
  • Thyroid, adrenal disease?*
  • Diabetes*
  • HIV/AIDS?*
  • Psychiatric care?*
  • Blood transfusion?*
  • Tumors, cancer?*
  • Osteoporosis?*
  • Radiation treatments or Chemotherapy?*
  • Arthritis, rheumatism?*
  • Allergies to: drugs, food, medications, latex, nickel*
  • Artificial joint?*
  • Headaches?*
  • Jaw popping, clicking, or difficulty opening*
  • Snoring*
  • Jaw pain, Dizziness, Difficulty chewing*
  • Excessively tired*
  • Use of a CPAP Machine*
  • Taking birth control pills*
  • Pregnant or could be*

  • ARE YOU TAKING?

  • Tobacco in any forms?*
  • Alcohol?*
  • Drugs, medications, over-the-counter medicines (Including aspirin), natural remedies?*
  • Recreational Drugs?*

  • III. ALL PATIENTS:

  • Is there anything else you think we should be aware of?*

  • IV: ALL PATIENTS

  • HAS ANY DOCTOR/PHYSICIAN EVER TOLD YOU THAT YOU NEED TO PRE-MEDICATE PRIOR TO ANY DENTAL APPOINTMENT?*
  • 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.
    Please sign once must be 18 and over to sign
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • HEADACHE AND FACIAL PAIN SCREENING QUESTIONNAIRE

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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:
  • Top of Head
  • Forehead
  • Back of Head
  • Pain in Head
  • Pain in Ear
  • Dizziness (vertigo)
  • Pain in Jaw Joint
  • Temples
  • Behind Eyes
  • Pain in Shoulder
  • Ear Congestion
  • Tinnitus (ringing in ears)
  • Facial Pain (non-specific)
  • Grating sound in joint
  • Clicking or popping in jaw joint
  • Partial inability to open mouth
  • Face muscle twitch
  • Difficulty swallowing
  • Difficulty breathing through nose
  • Difficulty chewing
  • Have you ever worn braces

  • 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:
  • Do you snore?
  • Are you excessively tired during the day?
  • Have you been told you stop breathing during sleep?
  • Do you have a history of hypertension?
  • Is your neck size greater than.......17 inches (male) | 16 inches (female)
  • 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: