Dental Registration And Health History
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3DENTAL REGISTRATION AND HEALTH HISTORY
Date
Patients Name__________________________________________________ How do you prefer to be addressed?
Sex: M F Age:________ Birth Date:________/________/________ Single Married Widow Separated Divorced SS#
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Mailing Address___________________________________________________City_________________________State_________Zip
Home #:_________________________________ Cell#:_________________________________ Work#:
Employer:__________________________________________________________ Occupation:
If Student, name of School / College:__________________________________ City___________________ State____________ Part Time or Full Time
Email Address:______________________________________ Whom may we thank for referring you to our office:
If the person responsible for this patients account is different from the patient or if this patient is a minor, the responsible
party must fill out the section below. Otherwise, please skip to the section titled “Insurance Information”
Name of responsible party______________________________________________ Relationship to Patient
Mailing Address___________________________________________________City_________________________State_________Zip
Sex: M F Age:________ Birth Date:________/________/________ Single Married Widow Separated Divorced SS#
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Home #:_________________________________ Cell#:_________________________________ Work#:
Email Address:______________________________________ Employer:_________________________ Occupation:
INSURANCE INFORMATION
Policy Holders Name__________________________________________________ Relationship to Patient
Social Security and/or Member ID #______________________________________________________ Date of Birth
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Name of Employer_________________________________________ Employer Address
Insurance Co._______________________________________ Phone #_(_______)__________-________________ Group #
Secondary Insurance Information
Policy Holders Name__________________________________________________ Relationship to Patient
Social Security and/or Member ID #______________________________________________________ Date of Birth
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Name of Employer_________________________________________ Employer Address
Insurance Co._______________________________________ Phone #_(_______)__________-________________ Group #
Answers to the following questions are for our records only and will be considered confidential.
1.
Have you or any member of your family been seen by us before?
YES
NO
If yes, Which family member (s)?
2.
Date of last physical examination________________________________ Physician’s name
3.
Date of last dental examination _________________________________ Date of last dental x-rays
4.
Previous Dentist’s Name _______________________________________ City/ State
5.
Are you having pain or discomfort at this time?
YES
NO
6.
Do you feel nervous about having dental treatment?
YES
NO
7.
Have you ever had a bad experience in a dental office?
YES
NO
8.
Is there anything you dislike about your smile?
YES
NO
9.
Is there anything you would like to speak with the doctor about in private?
YES
NO
10. Have you been a patient in the hospital during the past two years?
YES
NO
11. Have you been under the care of a medical doctor during the past two years?
YES
NO
12. Have you taken any medications or drugs in the past two years?
YES
NO
13. Are you taking any vitamins, herbal supplements or "cures"?
YES
NO
14. Have you ever had excessive bleeding requiring special treatment?
YES
NO
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Parent category: Medical