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New Patient Dental Registration -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Address

Street Address
Q4

Address

Street Address Line 2
Q5

Address

City
Q6

Address

State / Province
Q7

Address

Postal / Zip Code
Q8

Phone Number

Area Code
Q9

Phone Number

Phone Number
Q10

Relationship to Patient
Q11

Current Dentist (name and number)
Q12

Date of last Xrays
Q13

Current Physician (name and number)
Q14

Do you have any of the following diseases or problems?
Q15

Are you under the care of a physician?
Q16

If yes, include name, address, phone number and reason.
Q17

Are you in good health?
Q18

Have there been any changes in your health in the past year?
Q19

If yes, please explain.
Q20

Date of last physical exam?
Q21

Have you been hospitalized in the past 5 years?
Q22

If yes, list reason and date.
Q23

Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.
Q24

Do you wear contact lenses?
Q25

Do you use controlled substances (drugs)?
Q26

If yes, which ones?
Q27

Do you use tobacco?
Q28

If yes, what kind, how often.
Q29

Do you drink alcohol?
Q30

If yes, how many drinks in last 24 hours? How many per week?
Q31

How interested are you in stopping drugs, alcohol or tobacco use?
Q32

Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?
Q33

If yes, include date, type of replacement and any complications.
Q34

Provide orthopedic surgeons name and number.
Q35

Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)?
Q36

If yes, what type, dosage and when was it taken?
Q37

Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?
Q38

For which condition?
Q39

Are you?
Q40

Are you allergic to or had a reaction to the following?
Q41

If yes to any please specify type and reaction.
Q42

Please indicate if you have or have had any of the following diseases or problems.
Q43

If yes to any, list dates, kinds, controlled or uncontrolled
Q44

If yes to any of the following CHD conditions, antibioticprophylaxis is recommended. Consult physician.
Q45

Has a physician or dentist recommended that you take antibiotics prior to dental treatment?
Q46

Do you have any diseases or problems not listed above that you think I should know about?
Q47

If yes, what?
Q48

Grind your teeth?
Q49

Bite your cheek?
Q50

Tongue thrust?
Q51

Mouth breather?
Q52

Bulimic/ anorexic?
Q53

Cigar/cigarette?
Q54

Pipe?
Q55

Bite nails?
Q56

Smokeless tobacco?
Q57

Suck your thumb/finger?
Q58

Use a toothpick or stimulator?
Q59

Use chewing gum?
Q60

Eat candy?
Q61

Drink soft drinks?
Q62

If present or past to any, please list when, how often and what kind if applicable.
Q63

How often do you brush? When?
Q64

How often do you floss? When?
Q65

Do you use mouthwash? What type?
Q66

Other types of oral health instruments?
Q67

Personal or family history of oral cancers?
Q68

Are you currently experiencing pain in your mouth?
Q69

If yes, where at, what type and for how long?
Q70

Are your teeth sensitive to hot/cold
Q71

Are your teeth sensitive to biting or chewing?
Q72

Are your teeth sensitive to sweets?
Q73

If present or past to any, please explain.
Q74

Have you ever had orthodontic treatment?
Q75

Have you had a bite plate / guard?
Q76

Have you had periodontic treatment?
Q77

Have you had oral surgery?
Q78

Have you had a serious injury to your mouth or head?
Q79

If present or past to any, please list what, dates, and reasons.
Q80

What is your normal schedule for dental cleanings? (Ex. Every 6 mo)
Q81

Date of last dental appointment?
Q82

Any complications from dental treatment?
Q83

Do you participate in sports?