Registration

Medical & Dental History

Name*

First name M.I. Last name

Phone*

Phone number type

Email*

Date of Birth*

Physician's Name

Physician's City

Purpose of Initial Visit

Date of Last Physical Exam

Purpose of Last Dental Visit

Medications*

Date of Last Dental Visit

Previous Dentist's Name*

Previous Dentist's City*

Date of Last Teeth Cleaning

Frequency of Dental Visits*

Allergies*

Penicilin
Antibiotics
Anesthetics
Metals
Latex
Other

What other allergies should we be aware of?

Conditions*

What other conditions should we be aware of?

Health Factors*

Select all that apply.

Pregnancy or Potential Pregnancy
Tobacco Use
Alcohol Use
Other Controlled Substances
Previous Hospitalization Purpose

What was your previous hospitalization purpose?

Dental Goals*

Select all that apply.

Teeth Whitening
Orthodontics
Pain Relief
Alleviate Bad Breath
Replacement of Missing Teeth
Replacement of Old Metal Fillings
Other

What are your other dental goals?

Known Conditions*

Select all that apply.

Grind Teeth
Bleeding Gums
Bad Breath
Soreness in Jaw
Sensitivity to Heat, Cold, Sweet or Pressure
Loose, Shifted or Chipped Teeth
Food Impaction Between Teeth
Other

What are other known conditions?

Oral Hygiene Habits*

The frequency of brushing (times per day).

Less than once
Once
Twice
More than twice

Brush Type*

Manual
Electric

Frequency of Flossing*

Less than once
Once
Twice
More than twice

Oral Treatment History*

Orthodontics
Endodontics (Root Canal)
Gum Treatment/Surgery
Bridge Work
TMJ

Do you have any other health-related concerns?

Emergency Contact's Full Name

Emergency Contact's Phone*

Emergency Phone number type

I attest to the accuracy of the information on this page.

Signed Date

Signature*

Name

This field is for validation purposes and should be left unchanged.

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Medical & Dental History

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