Online Patient Registration

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P A T I E N T

Patient First Name:*

Patient Last Name:*

M.I.:

Patient Email Address:*

Date of Birth (M/D/Y):

Age:

Sex:*

Male

Female

Street:

Street Address City State / Province / Region ZIP / Postal Code

Home Tel:

Bus. Tel:

Ext.:

Dentist:

Orthodontist:

Physician:

Referred By:

Have you ever been a patient in our practice:

Yes

A C C O U N T

Who will be responsible for your account?:

Name:

Street:

Street Address City State / Province / Region ZIP / Postal Code

Home Tel:

Employer:

Tel:

I N S U R A N C E

Student

Full Time

Part Time

Not

School Name

School Address

Status

Employer

Full Time

Part Time

Retired

Not

PRIMARY DENTAL INSURANCE

Employer

Address

Bus. Tel

Insurance Company Name

Address

Phone

Group No.

Group Name

Insured Party

Relation

Sex

Yes

Date of Birth (M/D/Y):

Street:

Street Address City State / Province / Region ZIP / Postal Code

Phone:

ID No.:

SECONDARY DENTAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.:

Group Name:

Insured Party:

Relation:

Sex:

Yes

Date of Birth (M/D/Y):

Street:

Street Address City State / Province / Region ZIP / Postal Code

Phone:

ID No.:

Please fill out the health history to the best of your knowledge All patient information is confidential Although periodontists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's visit:

Are you in good health:

Yes

Height:

Weight:

Have there been any changes in your general health in the past year?

Yes

Are you under the care of a physician?

Yes

Date of last visit:

If so, for what are you being treated?

Have you had any illness, operation or been hospitalized in the past five years?

Yes

Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth?

Yes

If so describe where:

Do you have a prosthetic joint?

Yes

If so describe where:

Do you have a heart valve replacement or vascular graft?

Yes

If so describe where:

Have You Had or Do You Currently Have

Rheumatic fever?

Yes

Stroke?

Yes

Damaged heart valves/ mitral valve prolapse?

Yes

Thyroid trouble?

Yes

Heart murmur?

Yes

Diabetes?

Yes

High blood pressure?

Yes

Low blood sugar?

Yes

Low blood pressure?

Yes

Kidney trouble?

Yes

Chest pain, angina?

Yes

Are you on dialysis?

Yes

Heart attack(s)?

Yes

Swollen ankles, arthritis or joint disease?

Yes

Irregular heart beat?

Yes

Stomach ulcers?

Yes

Cardiac pacemaker?

Yes

Contagious diseases?

Yes

Heart surgery?

Yes

Sexually transmitted diseases?

Yes

Bronchitis, chronic cough?

Yes

Problems with the immune system?

Yes

Asthma?

Yes

Delay in healing?

Yes

Hay fever / Sinus problems?

Yes

A tumor or growth?

Yes

Tuberculosis?

Yes

X-Ray treatment / chemotherapy?

Yes

Emphysema?

Yes

Chronic fatigue / night sweats?

Yes

Difficult breathing / other lung trouble?

Yes

Are you on a diet?

Yes

Do you smoke?

Yes

A history of drug abuse?

Yes

Blood transfusion?

Yes

A history of alcohol abuse?

Yes

Blood disorder such as anemia?

Yes

Contact lenses?

Yes

Bruise easily?

Yes

Eye disease / glaucoma?

Yes

Bleeding tendency (abnormal bleed?)

Yes

Mental health problems?

Yes

Jaundice, hepatitis or liver disease?

Yes

A removable dental appliance?

Yes

Infectious mononucleosis?

Yes

Pain & Clicking of jaws when eating?

Yes

Gallbladder trouble?

Yes

Malignant Hyperthermia?

Yes

Fainting spells?

Yes

If you are having surgery today, have you had anything to eat or drink in the last 8 hours?

Yes

Convulsions, epilepsy?

Yes

Who is driving you home?

MEDICATION

Any kind of medicine, drugs, or pills?

Yes

Have you ever taken diet pills?

Yes

Anticoagulants?

Yes

Tranquilizers?

Yes

Cortisone?

Yes

Please list any other medications you are taking:

ALLERGIES Are You Allergic To Or Had A Reaction To...

Local anesthetics?

Yes

Codeine or other narcotics?

Yes

Penicillin?

Yes

Other medications?

Yes

Other antibiotics?

Yes

Latex?

Yes

Sodium pentothal, valium, or other tranquilizers?

Yes

Aspirin?

Yes

Please list any allergies other than drug allergies?

WOMEN

Is there a possibility of pregnancy?

Yes

Are you nursing?

Yes

Estimated delivery date?

Are you taking birth control pills?

Yes

WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

Is there any condition concerning your health that the doctor should be told?

Yes

Do you wish to speak to the doctor privately about anything?

Yes

Do you wish to speak to the doctor privately about anything?

Yes

FAMILY HISTORY
Is there a family history of :

Cancer

Yes

Heart Disease

Yes

Diabetes

Yes

Anesthetic Problems

Yes

IN CASE OF EMERGENCY, CONTACT

Name:

Telephone #:

Work #:

INJURY

Is this visit related to an accident?

Yes

Is this visit work related?

Yes

Other:

Yes

Date of Injury:

Insurance Company Handling The Claim:

Claim Number:

Name of Attorney / Adjustor:

Attorney / Adjustor Telephone #:

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