Dental Registration And Health History Page 2
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1
2
3ALLERGIES
MEDICATIONS
Aspirin
Local Anesthetic
Please list any medications you are currently taking:
Barbiturates
Penicillin
__________________________________________________________
Codeine
Sulfa
__________________________________________________________
Iodine
Metals
__________________________________________________________
Latex
Other:________________________
__________________________________________________________
Place a mark on YES or No to indicate if you have had any of the following:
Chest Pain
YES
NO
Hepatitis A (Infectious)
YES
NO
Use of tobacco products
YES
NO
Heart Failure
YES
NO
Hepatitis B (Serum)
YES
NO
Drug addictions
YES
NO
Heart Disease or Attack
YES
NO
Hepatitis C or other
YES
NO
Alcoholism
YES
NO
Heart Problems
YES
NO
Tuberculosis (TB)
YES
NO
Psychiatric Treatment
YES
NO
Heart Surgery
YES
NO
HIV positive, ARC, AIDS
YES
NO
Mental Retardation
YES
NO
*Mitral Valve Prolapse
YES
NO
Sickle Cell Disease
YES
NO
Birth Defects
YES
NO
*Congenital Heart Problems
YES
NO
Emphysema
YES
NO
Eating Disorder
YES
NO
*Heart Murmur
YES
NO
Diabetes
YES
NO
Fainting or dizzy spells
YES
NO
High Blood Pressure
YES
NO
Liver Disease
YES
NO
Epilepsy or seizures
YES
NO
Heart Pacemaker
YES
NO
Thyroid Disease
YES
NO
Persistent Cough
YES
NO
Stroke
YES
NO
Kidney Trouble
YES
NO
Asthma
YES
NO
Cancer (Type:
) YES
NO
Hemophilia
YES
NO
Shortness of Breath
YES
NO
Radiation Therapy
YES
NO
Jaundice
YES
NO
Hay Fever
YES
NO
Chemotherapy
YES
NO
Anemia
YES
NO
Hives or Skin Rash
YES
NO
*Steroid Treatment
YES
NO
Glaucoma
YES
NO
Sinus Trouble
YES
NO
*Artificial Joints
YES
NO
Arthritis
YES
NO
Herpes
YES
NO
*Any Type of Transplant
YES
NO
Ulcers
YES
NO
Cold Sores
YES
NO
*Any Type of Implant
YES
NO
Angina Pectoris
YES
NO
Bruise Easily
YES
NO
*Rheumatic Fever
YES
NO
Blood Transfusion
YES
NO
Dentures or Partials
YES
NO
OTHER:_______________________________
*
Antibiotic pre-medication may be required prior to your appointment
Have you been advised by your Physician to "Pre-Medicate" for dental appointments?
YES
NO
Have you ever experienced any of the following problems with your jaw:
Do you currently have any of the problems listed below?
Please circle all that apply:
Clicking
YES
NO
Swelling
Bad Taste
Pain in or around your ears
YES
NO
Bleeding Gums
Loose Teeth
Difficulty opening or closing
YES
NO
Sensitive to:
Do you have a history of trauma to your jaw?
YES
NO
Hot
Cold
Have you ever been diagnosed with TMJ/TMD?
YES
NO
Biting/ Pressure
Sweets
Other:___________________________________
Do you have any sores or lumps or growths in or near your mouth?
YES
NO
Problems with bad breath? (Halitosis)
YES
NO
Have you ever had difficult extractions in the past?
YES
NO
Do you have any trouble chewing?
YES
NO
Have you ever had prolonged bleeding following extractions?
YES
NO
Does food collect between your teeth?
YES
NO
Are there now any growths or sores in or around your mouth?
YES
NO
Have you ever had instructions in
Do you habitually clench or grind your teeth during
oral hygiene?
YES
NO
the day or night?
YES
NO
Have you ever taken Redux or
Pondimin (Fen Phen)?
YES
NO
Have you ever been told you have gum problems?
YES
NO
Have you ever needed to see a periodontist?
YES
NO
Do you now have bleeding gums or any other gum condition?
YES
NO
Is there anything related to your medical or dental history tat you have not indicated above?
YES
NO
If yes, please explain:__________________________________________________________________
WOMEN: Are you pregnant now?
YES
NO
If yes, what is your due date?
Are you currently breast feeding?
YES
NO
Are you taking oral contraceptives?
YES
NO
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I
understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis
and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/ or health
practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I
understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered
on my behalf or my dependents.
X_________________________________________________________________________
Date:
Signature of patient or guardian
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