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New Patient Registration


  Last name

  Mid name

  First name
    
    
City
State
Zip
APT#
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City
State
Zip
APT#

Adult Patient Details

Single Married Partnered Divorced/Separated Widowed
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Guardians and Child's Details


  Last name

  Mid name

  First name
    
Age:
City
State
Zip
APT#
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  Last name

  Mid name

  First name
    
Age:
City
State
Zip
APT#
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Employer Details
City
State
Zip
APT#

Spouse information
    
City
State
Zip
APT#
()- - -
    
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Relative or friend not living with you
()- - -
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Insurance information

Primary insurance
YesNo
City
State
Zip
APT#
()- -
City
State
Zip
APT#

Secondary insurance
YesNo
City
State
Zip
APT#
()- -
City
State
Zip
APT#

Medical History

YesNo
()- -
Good Fair Poor
YesNo
Explain :
YesNo
YesNo
YesNo
Explain :
YesNo
YesNo
YesNo
YesNo
Abnormal Bleeding / Hemophilia
AIDS related complex
Alcohol / Drug abuse
Allergies or Hives
Anemia
Angina pectoris
Arthritis
Artifical prosthesis
Artificial bones / Joints / Valves
Asthma
Blood disease
Blood transfusion
Cerebral palsy
Chemotherapy (cancer, leukemia)
Chicken pox
Colitis
Congenital heart defect
Congenital heart disease
Diabetes
Difficulty breathing
Drug addiction
Emphysema
Epilepsy / seizures
Excessive bleeding
Fainting spells / seizures
Frequent headaches
Glaucoma
Hay fever
Head injuries
Heart attack / Surgery
Heart failure
Heart murmur
Hepatitis / jaundice
Herpes / Fever blisters
High blood pressure
Hospitalized for any reason
Joint replacement
Kidney disease
Liver disease
Low blood pressure
Lupus
Mitral valve prolapse
Nervous disorder
Pacemaker
Psychiatric treatment
Radiation treatment
Respiratory disease
Rheumatic / Scarlet fever
Shingles
Sickle cell disease / Traits
Sinus problems
Sinus Trouble
Stroke
Thyroid problems
Tonsillitis
Tuberculosis (TB)
Tumors or growths
Ulcers
Venereal disease
X-Ray or cobalt treatment
Anesthetic (Novocain, ETC)
Aspirin
Barbiturates
Codeine
Dental anesthetics
Erythromycin
Iodine
Jewelry / Metals
Latex
Local anesthetics
Penicillin
Plastic
Sedatives
Sleeping pills
Sulfa Drugs
Tetracycline
Other

Dental history

Hot or cold?
Yes No
Sweets?
Yes No
Biting or Chewing?
Yes No
Have you noticed any mouth odors or bad tastes?
Yes No
Do you frequently get cold sores, blisters or any other oral lesions?
Yes No
Do your gums bleed or hurt?
Yes No
Have your parents experienced gum disease or tooth loss?
Yes No
Have you noticed any loose teeth or change in your bite?
Yes No
Does food tend to become caught in between your teeth?
Yes No
If yes, where?
Clench or grind your teeth while awake or asleep?
Yes No
Bite your lips or cheeks regularly?
Yes No
Hold foreign objects with your teeth?
(pencils, pipe, pins, nails, fingernails)
Yes No
Mouth breathe while awake or asleep?
Yes No
Have tired jaws, especially in the morning?
Yes No
Snore or have any other sleeping disorders?
Yes No
Smoke/chew tobacco or use other tobacco products?
Yes No
Orthodontic treatment?
Yes No
Oral Surgery?
Yes No
Periodontal treatment?
Yes No
Your teeth ground or the bite adjusted?
Yes No
A bite plate or mouth guard?
Yes No
A serious injury to the mouth or head?
Yes No
If so, please describe, including cause:
Clench or grind your teeth while awake or asleep?
Yes No
Clicking or popping of the jaw?
Yes No
Pain?(joint, ear, side of face)
Yes No
Difficulty in opening or closing the mouth?
Yes No
Difficulty in chewing on either side of the mouth?
Yes No
Headaches, neckaches or shoulder aches?
Yes No
Sore muscles (neck, shoulders)?
Yes No
Are you satisfied with your teeth’s appearance?
Yes No
Would you like to keep all of your teeth all of your life?
Yes No
Do you feel nervous about having dental treatment?
Yes No
If so, what is your biggest concern?

Have you ever had an upsetting dental experience?
Yes No
If so, please describe
Have you ever been sedated?
Yes No
For which type of dental treatment?
Usually get sedated for dental treatment?
Yes No
Any problems with sedation?
The information and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)