Registration and Medical History Forms
DENTAL HEALTH REASONS FOR FILLING OUT DENTAL AND MEDICAL HISTORY FORMS

We are frequently asked by patients as to why they need to fill out medical and dental history forms.  Patients often do not realize that their dental health affects their physical health and that their physical health affects their dental health.
When we get your complete medical and dental history, we are able to help you understand the connection between your oral health and general health.

Our dental exams can help diagnose periodontal disease (gum disease), cavities, oral cancer and other health conditions that maybe connected to diabetes, heart disease and other medical concerns.  Because of how these risk factors are related to each other you will be asked additional questions regarding your health.  By answering these questions, we are able to make recommendations that are  SPECIFIC TO YOU.

Medications that patients take can also have side effects that affect oral health.  Many patients are taking some kind of medication, and many of these medications could have a dental related side effect. Please take the time to answer these questions carefully so that we can give you the best care possible.
LAST                             FIRST                          MI   MR   MRS   MS  DR
ABOUT YOU
SPOUSAL INFORMATION
RESPONSIBLE PARTY
DENTAL INSURANCE
SECONDARY DENTAL INSURANCE
Today's Date
E-mail:
Name:
I prefer to be called:
Birth date:
Age:
Home Address:
City:
State:
Zip:
Home Phone:
Work#:
Cell #:
Employer:
Employer's address:
Occupation:
Best time and place to reach you:
Who may we thank for referring you?
Other family members seen by us?
Last dental visit date:
Emergency contact:
His/Her name:
Employer:
Work#:
Ext:
Birth date:
Person responsible for account:
Work#:
Ext:
Home#:
Billing address:
Relationship to patient:
Insurance Co. name:
Address:
Phone#:
Group # (plan, local policy#):
Insured's Name:
Relation:
Insured's birth date:
Insured's employer:
Employer's address:
Insurance Co. name:
Address:
Phone#:
Group# (plan, local policy#):
Insured's Name:
Relation:
Insured's birth date:
Insured's employer:
Employer's address:
GENERAL MEDICAL INFORMATION
Please rate your health
Has there been a change in your health in the past year?
. Physician
Phone #:
Date of last physical examination: 
Currently under the care of a physician?
Please explain:
Please explain:
Do you excercise regularly?
Do you need to take antibiotics prior to receiving dental or surgical care?
Reason:
MAJOR HOSPITALIZATIONS, SURGERIES, OR BLOOD TRANSFUSIONS
ALLERGIC OR UNUSUAL REACTION TO ANY OF THE FOLLOWING
WOMEN ONLY
Are you:
Weeks
PRESCRIPTIONS/NON-PRESCRIIPTION MEDICATIONS, VITAMINS, AND SUPPLEMENTS
Please list all                    Name                        For What Condition?                                 Dose/frequency of use
HEART/BLOOD DISORDERS
INFECTIOUS DISEASES
CHRONIC PAIN
LUNG/AIRWAY  DISORDERS.
HORMONAL/METABOLIC DISORDERS
NEUROLOGICAL DISORDERS
Other:
IMMUNE SYSTEM DISORDER
Other:

GASTROINTESTINAL DISORDERS
Other:
TOBACCO
Do you use tobacco?
If yes please answer the following questions
Type:
Amount:
Number of years:
Are you interested in quitting tobacco?
DENTAL INFORMATION
Previous Dentist:
Last Dental visit:
Last Dental prophylaxis:
Frequency of Dental exams:
Frequency of brushing:
Frequency of flossing:
What are some typical foods you eat between meals?
What type of beverages between meals?
Do you often use hard candy, cough drops or mints?
Do you use fluoridated toothpaste?
Primary sources of drinking water?.
PAST DENTAL HISTORY

One or more fillings in the last three yrs?
Family history of extensive decay?

Treatment for periodontal  (gum) disease?
Family history of periodontal disease?
Have you had orthodontics (Braces)?
Have you had oral surgery?
Have you had dental implants placed?
Treatment for TMJ disorders?
Do you wear dentures or partial dentures?
Click here to add text.
DO YOU HAVE ANY PROBLEMS WITH?
Dry mouth/excessive thirst?
Sensitive teeth or hot,cold
pressure, sweets

Mouth odors/bad taste?
Cold sores, blisters,oral lesions?

Are you aware of any swelling or
lumps?
Sore, bleeding gums?
Loose teeth?
Difficulty chewing?
Food catches between teeth?
Clenching or grinding habits?
Do you have jaw pain?
Does dental work make you
nervous?
Your smile or esthetics of your
anterior teeth?
Male
Female
Single
Married
Widowed
Divorced
Separated
Excellent
Very good
Good
Fair
Poor
Yes
No
Yes
No
Yes
No
Yes
No
None
Penecillin
Sulfa drugs
Aspirin
Local Anesthesia
Opiates/Codiene
Iodine
Latex
Jewelry
Other drugs
Other substances(food, metals,etc.)
Pregnant
going through menopausepost menopausal
High Blood Pressure
Stroke
Artherosclerosis
Heart Attack
Coronary artery disease
Heart murmur
Mitral valve prolapse
Heart surgery
Artificial heart valves
Pacemaker
Indwelling defibrillator
Bleeding disorders
Taking blood thinners
Strep throat
Mononucleosis
Hepatitis: Type
Sexually transmitted disease
HIV/AIDS
Back
Abdominal
Headache/Migraine
Emphysema
Pneumonia
Bronchitis
Asthma
Tuberculosis
Sleep apnea
Diabetes
Thyroid disease
Adrenal insufficiency
Epilepsy/seizures
Neuralgia
Parkinson's disease
Rheumatoid arthritis
Lupus erythematosus
Sjogren's syndrome
Acid reflux/heartburn
Ulcer/gastritis
Irritable bowel syndrome/colitis
Ulcerative colitis/chrohn's disease
YesNo
YesNo
YesNo
YesNo
City filtered water
City unfiltered water
Bottled water
Well water
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No