TRAN FAMILY DENTISTRY
DENTAL REGISTRATION AND HISTORY FORM
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create receive or maintain.
Refer to Privacy Practices Form. Your answers are for our records and will be kept confidential subject to applicable laws. Please note you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
DATE: ______HM PH: ______CELL PH: ______
PATIENT INFORMATION
Last Name:______First Name______MI ______
Address: ______City: ______State: ______Zip: ______Circle Sex: M F Age:______DOB: ______Single ____ Married ____ Widow ____ Separated ____ Divorced _____
Social Security Number: ______Driver’s License #: ______State: ______
Employed by:______Address:______Phone:______Referred by: Yellow Pgs: Hanford/Lemoore___ AT&T ___ Valley ___ / Insurance ___ Internet ___ Word of Mouth ___Other______
In case of emergency who should be notified? ______Phone: ______
Do you have any of the following diseases or problems: (Check Yes, No or DK if you don’t know the answer to the question)Yes No DK
1) Active Tuberculosis: ………………………………………………………………………………………………………………. ______
2) Been Exposed to anyone with Tuberculosis: …………………………………………………………………………………….. ______
3) Persistent cough greater than a 3 week duration ……………………………………………………………………………….. ______
4) Cough that produces blood: ………………………………………………………………………………………………………. ______
If you answer yes to any of the 4 items above, PLEASE STOP AND RETURN THIS FORM TO THE RECEPTIONIST.
DENTAL INFORMATION (Please check Yes, No or DK if you don’t know the answer to the question)
Yes No DKDo you have any broken teeth or fillings? ……………...... ______
Do your gums bleed when you brush or floss? …………….. ______
Are your teeth sensitive to cold, hot, sweets or pressure? … ______
Does food or floss catch between your teeth? …………….. ______
Is your mouth dry? ……………………………………...... ______
Have you had any periodontal (gum) treatments? ………. ______
Have you had any orthodontic (braces) Treatment? …….. ______
Are you currently experiencing dental pain or discomfort? ______
What is your reason for dental visit today? ______
______
Would you like to discuss cosmetic dentistry? (circle one) Yes No
Are you extremely nervous of dental treatment? (circle one) Yes No
/ Yes No DK
Any problems with previous dental treatment? ______
Do you have earaches or neck pains? ………... ______
Do you have clicking or popping of jaw? ……. ______
Do you brux or grind your teeth? ……………. ______
Do you have sores or ulcers in your mouth? … ______
Do you have Halitosis (bad breath) …………… ______
Do you wear dentures or partials? …………… ______
Any serious injury to your neck or mouth? … ______
Date of last Dental Examination: ______
What was done at that time: ______
Date of last X-rays taken: ______
Former Dentist: ______
MEDICAL INFORMATION (Please check Yes, No or DK if you don’t know the answer to the question)
Yes No DKAre you now under the care of a physician? …………………...... ______
Physicians Name: ______Phone #: ______
______
Address/ City/ State
Are you in good health? ……………………………………………………………...... ______
Have there been any changes in your general health within the past year? ……………………………………………………….. ______
If yes, what condition is being treated? ______
Date of last physical exam: ______
Have you had a serious illness, operation or been hospitalized in the past 5 years? ……………………………………………….. ______
If yes, what was the illness or problem? ______
Have you ever taken any of the diet medication collectively referred to as “Fen-Phen”? ………………………………………… ______(Redux , Ionimin, Adipox, Fastin, Pondimin)
Are you taking or have you recently taken any prescription or over the counter medicine(s)? ………………………………….. ______
If so, please list medications, dosage and reason for taking the medication:______
______
______
______
______
Also list vitamins, natural or herbal preparations and or diet supplements: ______
Please mark (x) your response to indicate if you have or have not had any of the following diseases or problems. Check DK if you don’t know answer to the question
Yes No DK Yes No DK
Joint Replacement. Have you had an orthopedic total joint Allergies: (Are you allergic or have you
(hip, knee, elbow, finger) replacement?...... ______reacted adversely to any of the following):
Date: ______If yes, any complications? ______Local anesthetic ……………………………... ______
Are you taking or scheduled to begin taking either of the Aspirin ………………………………………. ______
medications, alendronate (Fosamax) or risedronate (Actonel)
for osteoporosis or Paget’s disease? …………………………….. ______Penicillin or other antibiotics ……………… ______
Do you use controlled substances (drugs)? ……………………… ______Barbiturates, sedatives or sleeping pills ….. ______
Do you use tobacco (smoking, snuff, chew, bidis)? …………….. ______Sulfa drugs …………………………………. ______
WOMEN ONLY – Are you: Codeine or other narcotics ……………….. ______
Pregnant? (If yes, # of weeks ______) ..…………………….... ______Metals ………………………………………. ______
Taking birth control pills or hormonal replacement? ..………. ______Latex ………………………………………. ______
Nursing? ………………………………………………………… ______Other: ______
______
Please mark (x) your response to indicate if you have or have not had any of the following diseases or problems:
Artificial (prosthetic) heart valve ……………………………………………………………………………………………………… ______
Previous infective endocarditis ……………………………………………………………………………………………………….... ______
Damaged valves in transplanted heart ………………………...... ______
Congenital Heart Disease (CHD) ……………………………...... ______
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Please mark(x) your response 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 Yes No DK
Cardiovascular Disease ….. ______Hemophilia ……….... ______Diabetes (Type I or II) ______
Angina …………………….. ______Blood Transfusion … ______Gastrointestinal disease ______
Arteriosclerosis …………... ______If yes, Date______Thyroid problems ……. ______
Congestive Heart Disease… ______AIDS /HIV Infection ______Glaucoma ……………… ______
Heart Attack ……………… ______Arthritis ……………. ______Hepatitis / Jaundice
Heart Murmur …………… ______Rheumatoid Arthritis ______Liver disease ………. ______
Low Blood Pressure ……... ______Autoimmune disease ______Epilepsy ……………….. ______
High Blood Pressure …….. ______Systemic Lupus …… ______Fainting or Seizures …. ______
Other Congenital Asthma …………….. ______Neurological disorder ______
Heart defects ………… ______If yes, specify ______
Stroke …………………….. ______Bronchitis …………. ______Mental Health disorders ______
Mitral Valve Prolapse ….. ______Emphysema ……….. ______If yes, specify ______
Pace Maker ………………. ______Sinus trouble ……… ______Emotional problems ….. ______
Kidney problems ………… ______Tuberculosis ………. ______Osteoporosis …………. ______
Rheumatic Fever ………... ______Cancer/Chemo ……. ______Severe headache ……… ______
Abnormal bleeding ……… ______Radiation Treatment ______Sexual transmitted
Anemia ………………….... ______Disease …………... ______
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? ….. ______
If yes, Name of physician or dentist making recommendation ______Ph# ______
Do you have any disease, condition or problem not listed above that you think I should know about? ………….. ______
Please explain: ______
______
SIGNATURE
NOTE: Both Doctor and patients are encouraged to discuss any and all relevant 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 and that my dentist and her staff will rely 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 her staff responsible for any action they take or do not take because of errors or omissions that I have made in the completion of this form. I further certify that I, the undersigned, consent to the performing of x-rays, examinations and whatever dental treatment may be agreed upon to be necessary or advisable.
SIGNATURE OF PATIENT OR GUARDIAN (if patient is a minor) x______DATE: ______
PRINT NAME: ______
SIGNATURE OF DENTIST x______DATE: ______
HISTORY UPDATE (Please indicate any changes in the last six months: Address/Phone/Medications/Medical &Dental Information
DATE CHANGES PT SIGNATURE DR SIGNATURE