Patient Registration Form - American Dental Association Page 2
ADVERTISEMENT
1
2Medical Information
Please mark (X) your responses to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don’t Know the answer to the question) Yes No DK
Yes No DK
Have you had a serious illness, operation or been
o o o
Are you now under the care of a physician? . . . . . . . . . . . . . . . .
o o o
hospitalized in the past 5 years? . . . . . . . . . . . . . . . . . . . . . . . . .
Physician Name: ____________________________________________________
If yes, what was the illness or problem? _______________________________
Phone:
( ______ ) _____________________________________
include area code
Are you taking or have you recently taken any prescription
Address/City/State/Zip: ______________________________________________
o o o
or over the counter medicine(s)? . . . . . . . . . . . . . . . . . . . . . . . . .
___________________________________________________________________
If so, please list all, including vitamins, natural or herbal preparations and/
o o o
Are you in good health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
or diet supplements: ________________________________________________
Has there been any change in your general health within
___________________________________________________________________
o o o
the past year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
___________________________________________________________________
If yes, what condition was treated? ___________________________________
___________________________________________________________________
___________________________________________________________________
Do you use controlled substances (drugs)? . . . . . . . . . . . . . . . .
o o o
Date of last physical exam: __________________________________________
Do you use tobacco (smoking, snuff, chew, bidis)? . . . . . . . . . .
o o o
o o o
Do you wear contact lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . .
If so, how interested are you in stopping?
Are you taking, or have you taken, any diet drugs such as
Circle one: VERY / SOMEWHAT / NOT INTERESTED
Pondimin (fenfluramine), Redux (dexphenfluramine) or fen-phen
o o o
Do you drink alcoholic beverages? . . . . . . . . . . . . . . . . . . . . . . .
o o o
(fenfluramine-phentermine combination)? . . . . . . . . . . . . . . . . .
If yes, how much alcohol did you drink in the last 24 hours? _____________
Are you taking or scheduled to begin taking either of the
If yes, how much do you typically drink in a week? ______________________
medications alendrontate (Fosamax®) or risendronate (Actonel®)
WOMEN ONLY Are you:
o o o
for osteoporosis or Paget’s disease? . . . . . . . . . . . . . . . . . . . . .
o o o
Since 2001, were you treated or are you presently scheduled to begin
Pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
treatment with the intravenous bisphosphonates (Aredia® or Zometa®)
Number of weeks: __________________________________________________
for bone pain, hypercalcemia or skeletal complications resulting from
Taking birth control pills or hormone replacement? . . . . . . . . . .
o o o
Paget’s disease, multiple myeloma or metastic cancer? . . . . . .
o o o
o o o
Nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date Treatment Began: _____________________________________________
o o o
Joint Replacement. Have you had an orthopedic total joint replacement (hip, knee, elbow, finger)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: ________________________
If yes, have you had any complications?
Allergies - Are you allergic to, or have you had a reaction to: Yes No DK
To all yes responses, specify type of reaction.
o o o
Metals __________________________________________________
o o o
Local anesthetics ________________________________________
o o o
Latex (rubber) ___________________________________________
o o o
Aspirin _________________________________________________
Iodine __________________________________________________
o o o
Penicillin or other antibiotics ______________________________
o o o
o o o
Hay fever / seasonal _____________________________________
o o o
Barbituates, sedatives, or sleeping pills _____________________
o o o
Animals ________________________________________________
o o o
Sulfa drugs _____________________________________________
Food ___________________________________________________
o o o
o o o
Codeine or other narcotics ________________________________
o o o
Other___________________________________________________
Yes No DK
Yes No DK
Yes No DK
Yes No DK
o o o
o o o
o o o
o o o
Heart murmur . . . . . . . .
Anemia . . . . . . . . . . . . .
Chest pain upon exertion
Neurological disorders .
o o o
o o o
o o o
Mitral valve prolapse . . .
Blood transfusion . . . . .
Chronic pain . . . . . . . . .
If yes, specify: _______________
o o o
o o o
o o o
Artificial heart valves . . .
If yes, date: __________________
Diabetes Type I or II . . .
Sleep disorder . . . . . . . .
o o o
o o o
o o o
o o o
Rheumatic fever . . . . . .
Hemophilia . . . . . . . . . .
Eating disorder . . . . . . .
Mental health disorders .
o o o
o o o
o o o
Cardiovascular disease .
AIDS or HIV infection . . .
Malnutrition . . . . . . . . . .
If yes, specify: _______________
o o o
o o o
o o o
o o o
Angina . . . . . . . . . . . . . .
Arthritis . . . . . . . . . . . . .
Gastrointestinal disease
Recurrent infections . . .
o o o
o o o
Arteriosclerosis . . . . . . .
Autoimmune disease . . .
G.E. Reflux/Persistent
Type of infection: _______________
Congestive heart failure
o o o
Rheumatoid arthritis . . .
o o o
heartburn . . . . . . . . . .
o o o
Kidney problems . . . . . .
o o o
o o o
o o o
o o o
Coronary artery disease
Systemic lupus
Ulcers . . . . . . . . . . . . . .
Night sweats . . . . . . . . .
o o o
o o o
o o o
o o o
Damaged heart valves . .
erythematosus . . . . . .
Thyroid problems . . . . .
Osteoporosis . . . . . . . . .
o o o
o o o
o o o
Heart attack . . . . . . . . . .
Asthma . . . . . . . . . . . . .
Stroke . . . . . . . . . . . . . .
Persistent swollen
o o o
o o o
o o o
o o o
Low blood pressure . . . .
Bronchitis . . . . . . . . . . .
Glaucoma . . . . . . . . . . .
glands in neck . . . . . .
o o o
o o o
High blood pressure . . .
Emphysema . . . . . . . . . .
Hepatitis, jaundice or
Severe headaches/
o o o
o o o
o o o
o o o
Congenital heart defects
Sinus trouble . . . . . . . . .
liver disease . . . . . . . . . .
Migraines . . . . . . . . . .
o o o
o o o
o o o
o o o
Pacemaker . . . . . . . . . .
Tuberculosis . . . . . . . . .
Epilepsy . . . . . . . . . . . . .
Severe of rapid weight loss
Rheumatic heart disease
o o o
Cancer/Chemotherapy/
Fainting spells or
Sexually transmitted disease
o o o
o o o
o o o
o o o
o o o
Abnormal bleeding . . . .
Radiation treatment . .
seizures . . . . . . . . . . .
Excessive urination . . . .
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o o o
Name of physician or dentist making recommendation: ___________________________________________
Phone: ( _________ )_______________________
o o o
Do you have any disease, condition, or problem not listed above that you think I should know about? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please explain: __________________________________________________________________________________________________________________________
NOTE: Both Doctor and patient are encouraged to discuss any and all relevent patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful
health history and that my dentist and his/her staff will reyl on this information for treating me. I acknowledge that my questions, if any, about inquiries set
forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take
or do not take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian: ____________________________________________________________________
Date: ___________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business