FormsGetting to know you formpatient Registration FormHealthy History form Getting To Know You Getting To Know You Name * Date * Please describe the reason for your consolation today: * How long has this been going on and what other events apply to today's visit? * Why have you decided to deal with this now? * Have you consulted with any other dentist about this? * Yes No If yes what was discussed or done? * When was your last dental checkup * Who is your regular or previous dentist? * Have you noticed or has any dentist or hygienist ever said to you (Check all that apply): Have gum disease (Gingivitis) Grind your teeth Clicking or popping jaw Jaw Pain or Tenderness Pain around the ear Lip or cheek biting Loose or broken teeth or fillings Food collection between teeth Sores, blisters or growths Bad Breath Do you have sensitivity to (Check all that apply) Cold Heat Sweets When biting or chewing Would you like to know your options to (Check all that apply) Improve your smile Look younger Keep your teeth What are your priorities and what would you like to see down now? * If you are human, leave this field blank. Patient Registration and Health History Patient Registration and Health History Full Name * Birthdate * Social Insurance # * Full Address & Postal Code * Phone Number * Work Phone Number Email Address * Social Insurance Carrier Group Number ID Number Employer Basic (%) Crown/Bridge (%) Rem. Pros. (%) Ortho (%) Name of Spouse Birthdate of Spouse Social Insurance Carrier (Spouse) Group Number (Spouse) ID Number (Spouse) Employer (Spouse) Basic (%) Crown/Bridge (%) Rem. Pros. (%) Ortho (%) Whom may we thank for referring you to our office? Medical History Physician Name * Physician Phone Number * Are you in Good Health? * Yes No Do you smoke? * Yes No Have you ever had a serious illness, operation, or hospitalization? * Yes No Are you now under the care of a physician for any ongoing treatment or therapy?. * Yes No My last physical examination was on: * Are you now taking any medicine, drugs, or pills? Yes No If yes, please list: * Do you have any allergies? Yes No If yes, to what? * Do you have or have you had any of the following diseases or problems (Please check all that apply)? Any Heart Disease Artificial Heart Valve High Blood Pressure Asthma Tuberculosis Any Lung Disease Hives or Skin Rash Any Kidney trouble Hepatitis Jaundice Any Liver Disease Ulcers Any Arthritis Rheumatic Fever Cancer AIDS Drug Addiction Hemophilia Mental or Nervous Disorder Epilepsy Do you, or has any member of your family had diabetes? * Yes No Do you have any blood disorders or do you bleed excessively? Yes No Do you have a prosthetic implant? (i.e. hip?) * Yes No Do you have a tendency to faint? * Yes No Do you have frequent severe headaches? * Yes No Are you on a special diet? * Yes No Have you ever had injury, surgery, or X-ray therapy to face or jaws? * Yes No WOMEN ONLY - Are you pregnant? (Which month: Do you have any disease, condition, or problem not listed above that you think the Dentist should know about? If yes, please explain: Today's Date * My Full Name Is * I Acknowledge that the above information is true and correct * Yes Dental History What concerns you most about your dental health? * Do you see a dentist on a routine basis? * Yes No Date of last dental visit? * Date of last dental cleaning? * Date of last full mouth series of X-rays? * Are you having pain at this time? Yes No Have you ever had (Check all that apply): Orthodontic treatment (Braces) Oral Surgery Periodontal treatment (Gum Surgery) Worn a bite guard or other appliance Have you noticed any loosening of your teeth? * Yes No Does food tend to become caught between your teeth? * Yes No Do you suffer from pain and/or swelling of your gums? * Yes No Do your gums often bleed when you brush your teeth? * Yes No Problems of the jaw. Have you experienced: (Check all that apply): Clicking of the jaw? Pain (joint, ear, side of face)? Difficulty in opening or closing? Difficulty in chewing? Habits. Do you: (Check all that apply): Clench or grind your teeth while awake or asleep? Bite your lips or cheeks regularly? Hold foreign objects with your teeth (such as pencils, pipe, pins, nails, fingernails) Difficulty in chewing? Do you feel nervous about having dental treatment? * Yes No Have you ever had an upsetting experience in a dental office? * Yes No Is it important to keep your teeth? * Yes No Are you dissatisfied with the appearance of your teeth? * Yes No If you could, what features of your smile would you like to change? * Is there anything else about having dental treatment that bothers you? * Yes No Please explain: Insurance companies now only allow for "functionally acceptable work", whereas, in the past their coverage was for "quality work". It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. The highest quality dentistry available The most economical treatment plan Dentistry limited to insurance coverage A combination of the above Please explain: * The undersigned hereby authorizes the Dentist to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Dentist to make a thorough diagnosis of the patient's dental needs. I also authorize the Dentist to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with (name of Patient): * after discussion and consultation between the named patient (or guardian of) and the dentist including alternative options or the consequences of no treatment. I also understand the use of anesthetic agents embodies a certain risk. Yes I Understand the Risks PATIENT (OR LEGAL GUARDIAN IF PATIENT IS UNDER THE AGE OF 18) * Today's Date * If you are human, leave this field blank.