Patient Registration Form - Dentistry Page 2

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DENTAL HEALTH AND APPEARANCE
ARE YOU PREGNANT?_YES/NO
IF YES, WHEN IS THE EXPECTED DELIVERY DATE?_________________________
DO YOU USE TOBACCO? YES/NO
IF YES, HOW MUCH?________________________________________________
HAVE YOU EVER BEEN TOLD TO PRE-MEDICATE FOR DENTAL WORK? YES/NO
HAVE YOU EVER TAKEN ORAL BISPHOSPHONATES? YES/NO
ARE YOU ALLERGIC TO ANY MEDICATION(S)?_YES/NO
IF YES, WHICH MEDICATION(S)?_______________________________________________________________
ARE YOU TAKING ANY MEDICATION NOW? YES/NO
IF YES, PLEASE LIST CURRENT MEDICATION(S):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR VISIT?________________________________ DATE OF LAST DENTAL VISIT? ____________________
HAVE YOU EVER HAD ANY SERIOUS PROBLEM(S) ASSOCIATED WITH PREVIOUS DENTAL TREATMENT? YES/NO
IF YES, PLEASE EXPLAIN:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PLEASE CHECK ANY OF THE CONDITIONS YOU HAVE HAD OR CURRENTLY HAVE:
Heart failure
Heart Disease or Attack
Angina Pectoris
Tuberculosis (TB)
Asthma
Artificial Heart Valve
Pacemaker
Anemia
Artificial Joint
Stroke
Kidney Trouble
Liver Disease
Diabetes
Cancer
Cortisone Medication
Hepatitis
HIV positive (AIDS)
Glaucoma
High Blood Pressure
Pain in Jaw Joints
Bruise Easily
Drug Addiction
Hemophilia
Epilepsy or Seizures
IF YOU ANSWERED YES TO ANY OF THE PREVIOUS CONDITIONS, PLEASE EXPLAIN:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PLEASE LIST ANY PREVIOUS
SURGERIES:____________________________________________________________________________________
_____________________________________________________________________________________________
Patient Initials:

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