Patient Registration

DateTime

I. PATIENT INFORMATION

First Name*

Middle Initial*

Last Name*

Age*

Date of Birth*

MonthDayYear

gender

Marital Status (Optional)

SS#*

Address*

City/State*

Home phone*

Zip Code*

Cell Phone

Work Phone*

Referred by*

How did you hear about Dr. Traub?*

Pharmacy: Name & Address *

Have you ever been treated by Dr. Traub before?

General Dentist

In Case of Emergency, Please Notify*

Name & Relationship

*

Phone

II. EMPLOYMENT INFORMATION

Patient's Employer

Employer Address

City/State/Zip

Phone

Spouse's Name

SS#

Spouse's Employer

Employer address

City/State/Zip

Phone

III. INSURANCE INFORMATION

Dental Insurance

Name of Carrier

Group #

Subscriber

Subscriber SS#

Birthdate

Plan

Medical or Secondary Dental Insurance

Name of Carrier

Group #

Subscriber

Subscriber SS#

Birthdate

Plan

1. Have you ever been treated for heart disease? If yes, what disease(s): Heart Attack?

YesNo

2. Are you being treated for any heart disease? If yes, what disease(s):

YesNo

3.Have you ever had Rheumantic fever?

YesNo

4. Do you have high blood pressure (hypertension) If yes, do you take medication? What medication?

YesNo

5. Do you have low blood pressure? Do you have a history of hypoglycemia?

YesNo

6. Are you anemic? Do you have any history of slow wound healing?

YesNo

7. Do you have Diabetes (sugar in blood)? If yes, do you take insulin

YesNo

8. Are you on any kind of special diet at this time?

YesNo

9. do you have Thyroid Gland Disease?

YesNo

10. Do you have any history of tumors or growths?

YesNo

11. Do you have Asthma?

YesNo

12. Have you ever been told or do you think that you have a bleeding disorder? If applicable, do you have any history of sickle cell?

YesNo

13. Have you ever had Hepatitis, liver or kidney disease?

YesNo

14. Do you have any history of ulcers, stomach or intestinal problems?

YesNo

15.Do you have a seizure disorder (Epilepsy)?

YesNo

17. Have you been in the hospital recently for a serious illness?

YesNo

16.Do you have a history of fainting?

YesNo

18. Have you ever had any operations? If so, what?

YesNo

19. Are you allergic to any drugs/medications? If yes, list them:

YesNo

20. Are you allergic to any non-medical substances? If yes, list them:

YesNo

21. Are you taking any drugs/medications right now (including birth control) If you are on multiple medications, please provide us with us with a list.

YesNo

22. Are you pregnant? If so, how may months? Are you taking pre-natal vitamins?

YesNo

23.Do you wear contact lenses?

YesNo

24. Do you have any history of radiation therapy?

YesNo

25. Do you have a cold?

YesNo

26. Do you have night sweats or weight loss?

YesNo

27. Have you ever suffered a serious head or facial injury?

YesNo

28. Do you have AIDS/ ARC? Or are you HIV +

YesNo

29. Do you have history of any other venereal disease/STD?

YesNo

30. Do you smoke? If yes, packs per day X how many years

YesNo

31. Have you ever had a difficult extraction? Dry socket?

YesNo

33. Do you have any history of prolonged bleeding after an extraction?

YesNo

34. Does your jaw pop or click when you chew?

YesNo

I certify that this information is true and correct to the best of my knowledge and that I will notify Dr. Traub of any changes in my health status or the information listed.

Signature*

This is a fill in the blanks field. Please add appropriate blank fields and text.