ONLINE REGISTRATION
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*Patient Name (Last, First, MI):

*Date of Birth(00/00/0000):

/ /          Sex Male  Female
*Social Security No: - -
Driver's License No:
*Street Address:
*City:
*State: *Zip:
*Home Phone: - -
Cell Phone: - -
E-mail Address:
Employed By:
Occupation:
Length of Employment:
Address of Employer:
City:
State Zip:
Name of Spouse:
Spouse's Work Phone No: - -
Children Name(s)
Name of Nearest Relative
(not spouse)
Address of Nearest Relative:
Phone No. of Nearest Relative: - -
Dental Insurance Coverage Yes  No
Name of Insurance Co:

Relationship of Patient to Insured/ Responsible Party:

Spouse  Self Dependent 
Other    Explain:

**IF THE ABOVE PATIENT IS NOT THE PERSON WHO IS PAYING
 THE BILL OR THE INSURED EMPLOYEE PLEASE FILL OUT THE SECTION BELOW**
Responsible Party's Name:
Date of Birth: / /          Sex Male  Female
Driver's License No:
Street Address:
City:
State: Zip:
Home Phone: - -
Work Phone: - -    ext: 
Social Security Number: - -
Employed By:
How long?
Address:
City:
State: Zip:


 

Who Referred you to our office?

Friend

 Name: 

Family Member 

Name:   

Yellow Pages

  

Dental Referral Service

  

Internet

  

Other 




 

Please identify your current dental need or reason for dental visit.

Dental Checkup

 Tooth Related Problem

Consult with Doctor

 Second opinion

Other, please specify

DENTAL HEALTH QUESTIONS:

A. HYGIENE

Brush Frequency (1,2,3, MORE)

 Yes   No      or Give Details: 

Floss

 Yes   No      or Give Details: 

Food Traps

 Yes   No      or Give Details: 

Gums bleed when floss or brush

 Yes   No      or Give Details: 

History of Gum Therapy

 Give Details: 

Type of Tooth Brush (Electric or manual; If manual: hard or Soft Bristles:

 Electric   Manual
Hard Bristle     Soft Bristle     

B. TMJ/JOINT/BITE

Grind of Clinch at Night:

 Yes   No      or Give Details: 

Headaches/Migraines:

 Yes   No      or Give Details: 

Jaw Clicks or pops when open:

 Yes   No      or Give Details: 

Jaw pain on opening wide:

 Yes   No      or Give Details: 

Jaw pain on chewing:

 Yes   No      or Give Details: 

Teeth-Contact evenly or uneven when close:

 Even   Uneven      or Give Details: 

History of Bite Adjustment

 Give Details: 

C. COSMETIC & ORTHODONTIC

Satisfied with appearance of your teeth:

 Yes   No      or Give Details: 

Interested in whitening your teeth:

 Yes   No      or Give Details: 

Interested in straightening your teeth using Invisalign or conventional braces:

 Yes   No      or Give Details: 

Interested replacement of any missing teeth: Partials, Bridges, or Implants:

 Yes   No      or Give Details: 

D. DENTAL- MEDICAL QUESTIONS

Do you smoke?
List packs per day:

 Yes   No      or Give Details: 

Do you chew tobacco:

 Yes   No      or Give Details: 

Noticeable lesions in the mouth:

 Yes   No      or Give Details: 

Swelling evident in the mouth:

 Yes   No      or Give Details: 

Any loose teeth:

 Yes   No      or Give Details: 

E.  DENTAL COMPLICATIONS

During Tooth Extraction
(Bleeding, Dry Socket, Infection)

 Yes   No      or Give Details: 

With use of nitrous oxide:

 Yes   No      or Give Details: 

With use of local anesthetic:

 Yes   No      or Give Details: 

Difficult to numb:

 Yes   No      or Give Details: 

Sinus Complications:

 Yes   No      or Give Details: 

Use of Sedation (Oral or IV):

 Yes   No      or Give Details: 

Reaction to an antibiotic:

 Yes   No      or Give Details: 

Reaction to a pain medication:

 Yes   No      or Give Details: 

F. DENTAL HISTORICAL BACKGROUND

Last Dental Visit (Approximate):

  

Last Cleaning:

  

Last Full Mouth X-ray taken   
(series of 18 x-rays of your teeth):

  

Please comment on any special request or anything you may like changed from your former dental visit, to make your visit here pleasurable (Dr. Z is committed to service)

  

DENTAL PERSONAL EXPERIENCE: 

Are there any specific dental goals you desire?

  

Is there any kind of treatment that you do not want us to perform?

 

Do you have any fears of having dentistry done?  If yes, please explain

 

Do you prefer to have a stereo, headphones, or television during your treatment to drown out any sounds?

  

Do you prefer your dental treatment with nitrous oxide? (Gas)

  

Lastly, is there any pertinent information you may want to tell us to make your dental experience professional and pleasurable?

  

 




MEDICAL HISTORY

Name of your medical doctor?

Address:
Phone: - -

Date of last physical exam:

Are you currently under a doctor's care?

 Yes   No

Have you been hospitalized
during the past 3 years?

For what?

Do you use tobacco in any form?

 Yes   No
Check if your family has any of the following medical problems:

diabetes     heart disease     high blood pressure     blood problems

Are you taking any medication by prescription or over the counter in the last 3 months?

Are you allergic to any medication? 
Please list:

Have you had any of the following medical problems?

Heart Disease

Heart Attack

Heart Murmur

Heart Pacemaker

Mitral Valve Prolapse

Rheumatic Fever

Chest Pain

Swollen Ankles

Shortness of Breath

Lung Problems

Asthma

Tuberculosis

Epilepsy

Seizures

Nerve Disorder

Paralysis

Venereal Disease

Herpes

Aids

Jaundice (Yellow Fever)

Liver Problems

Hepatitis

Bleeding Problems

Anemia

High Blood Pressure

Low Blood Pressure

Fainting Spells

Sickle Cell Anemia

Kidney Problems

Diabetes

Thyroid Problem

Cancer

Malignancy

Healing Slow

Stomach Disorder

Prosthetic Replacement

Arthritis

 

Other:

If female, are you pregnant?

Yes   No
   
I have read and understand to the best of my knowledge
the information pertaining to the patient's dental and medical history is true.

Yes     No

*Indicates Required Field



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of your visit to verify that the information if correct.




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