Patient Registration

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11/03/2026Click to Sign
PATIENT INFORMATION
Sex
Has a family member ever been a patient of our practice?
Have you ever been a patient of our practice?
Cash
Check
Credit Card
Person Responsible For Account
Student
Marital Status
Employed
Do you belong to a PPO or an HMO?
Primary Dental Insurance Sex
Secondary Dental Insurance Sex
Primary Medical Insurance
Secondary Medical Insurance
Are you in good health?
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Have you had any illnesses, operations, or been hospitalized in the past five years?
Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots in or around your mouth?
Do you have a prosthetic joint/implant?
Have you had a heart valve replacement or vascular graft?
Have you ever had general anesthesia?
Have you or a family member had any unusual or serious reactions to general anesthesia?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Rheumatic Fever
Difficulty BreathingOther
Thyroid Trouble
A Tumor or Growth
Damaged Heart Valves
Tuberculosis
Diabetes
CancerRadiation Therapy
Heart Murmur
Emphysema
Low Blood Sugar
Chronic FatigueNight Sweats
High Blood Pressure
Blood Transfusion
Kidney Trouble
On Diet
Low Blood Pressure
Blood Disorder
High Cholesterol
History of Alcohol Abuse
Chest PainAngina
On Dialysis
History of Drug Abuse
Heart Attacks
Bruise Easily
Swollen AnklesArthritis
Contact Lenses
Irregular Heart Beat
Bleeding Tendency
OsteoporosisOsteopenia
Eye DiseaseGlaucoma
Cardiac Pacemaker
Osteonecrosis
Mental Health Problems
Heart Surgery
HepatitisJaundice
Stomach UlcersAcid Reflux
PneumoniaBronchitis
Infectious Mononuculeosis
Contagious Diseases
Removable Dental Appliance
Mitral Valve Prolapse
Gallbladder Trouble
Sexually Transmitted Diseases
Pain or Clicking in Jaws
Asthma
Fainting Spells
Problems With Immune System
Smoke Tobacco
Hay FeverSinus Problems
ConvulsionsEpilepsy
SnoringSleep Apnea
Stroke
Delay in Healing
Chew Tobacco
Is there a possibility of pregnancy?
Are you nursing?
Are you taking birth control pills?
Local Anesthetic or Numbing Medications
Other Tranquilizers
Latex
Penicillin
Aspirin
Soy
Other Antibiotics
Amoxicillin
Eggs or Yolk
Sulfa Drugs
Codeine or Other Narcotics
Sulfites
Sodium Pentothal or Valium
Other Medications
Any Other Allergies Not Listed
Any Medication Drug or Pills
Any Natural Product Herbal Supplement or Homeopathic Remedy
Blood Thinners Coumadin Plavix Aspirin
Bone Density Medications or Bisphosphonates Such as Fosamax
Tranquilizers Sleeping Pills Antidepressants
Diet Pills
Cancer
Diabetes_2
Heart Disease
Anesthesia Problems
If you are having surgery today, have you had anything to eat or drink in the past six hours?
Is there any condition concerning your health that the doctor should be told about?
Do you wish to speak to the doctor privately about anything?
Is this visit related to an accident?
Automobile
WorkRelated
Other_2
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11/03/2026Click to Sign
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11/03/2026Click to Sign
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