Patient Registration Form Welcome To Our Dental OfficeDate* MM slash DD slash YYYY The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.Registration Information This information will enable us to maintain communication with you.The patient is an: Adult Child Adult under guardianship Name of Guardian:* Name: Dr.MissMr.Mrs.Ms.Prof.Rev. (salutation) (first) (initial) (last) Prefers to be called: Address:* (street) (appt.#) (city) AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon (province) (postal code) Home Phone:*Alberta Health Care Number: Occupation: Cell Phone:Email: Date of Birth:* MM slash DD slash YYYY Age: Sex: Whom may we thank for referring you? Medical Priority This information will enable us to make any essential contacts.Family Physician: Phone:In case of emergency, please contact: Phone:Primary Dental Insurance (If information required by office)Insurance Company: Policy Holders Name: DOB: MM slash DD slash YYYY Group/ Policy Number: Certificate/ ID Number: Secondary Dental InsuranceInsurance Company: Policy Holders Name: DOB: MM slash DD slash YYYY Group/ Policy Number: Certificate/ ID Number: Patient Registration & Dental HistoryDental History Previous Dentist: Date of most recent dental exam: MM slash DD slash YYYY Date of most recent x-rays: MM slash DD slash YYYY Medical History Do You Have Or Have You Ever Had 1. Hospitalization for illness or injury Yes No Please Explain*2. Allergic reaction to:Aspirin, ibuprofen, acetaminophen, codeine Yes No Penicillin Yes No Erythromycin Yes No Tetracycline Yes No Sulfa Yes No Local Anesthetic Yes No Fluroide Yes No Metals (nickel, gold, silver) Yes No Latex Yes No Other Yes No Please Specify 3. Heart problems, or cardiac stent within the last six months Yes No 4a. History of infective endocarditis Yes No 4b. Do you require a premedication Yes No 5. Artificial heart valve, repaired heart defect (PFO) Yes No 6. Pacemaker or implantable defibrillator Yes No 7. Artificial prosthesis (heart valve or joints) Yes No 8. Rheumatic or scarlet fever Yes No 9. High or low blood pressure Yes No 10. A stroke (taking blood thinners) Yes No 11. Anemia or other blood disorder Yes No 12. Prolonged bleeding due to a slight cut (INR > 3.5) Yes No 13. Emphysema, shortness of breath, sarcoidosis Yes No 14. Tuberculosis, measles, chicken pox Yes No 15. Asthma Yes No 16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) Yes No 17. Kidney disease Yes No 18. Liver disease Yes No 19. Jaundice Yes No 20. Thyroid, parathyroid disease, or calcium deficiency Yes No 21. Hormone deficiency Yes No 22. High cholesterol or taking statin drugs Yes No 23. Diabetes (HbA1c) Yes No 24. Stomach or duodenal ulcer Yes No 25. Digestive disorders (i.e. celiac disease, gastric reflux) Yes No 26. Osteoporosis/osteopenia (i.e. taking bisphosphonates) Yes No 27. Arthritis, rheumatoid arthritis, lupus Yes No 28. Glaucoma Yes No 29. Contact Lenses Yes No 30. Head or neck injuries Yes No 31. Epilepsy, convulsions (seizures) Yes No 32. Neurologic disorders (ADD/ADHD, prion disease) Yes No 33. Viral infections and cold sores Yes No 34. Any lumps or swelling in the mouth Yes No 35. Hives, skin rash, hay fever Yes No 36. STI / STD Yes No 37. Hepatitis (type ) Yes No Please specify type: 38. HIV / AIDS Yes No 39. Tumor, abnormal growth Yes No 40. Radiation therapy Yes No 41. Chemotherapy, immunosuppressive Yes No 42. Psychiatric treatment Yes No 43. Antidepressant medication Yes No 44. Alcohol Yes No 45. Street drug use Yes No If yes, please confirm drug name(s):Are You: 46. Presently being treated for any other illness Yes No If yes, please explain:47. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) Yes No 48. Taking vitamins/other supplements Yes No 49. Often exhausted or fatigued Yes No 50. Experiencing frequent headaches Yes No 51. A smoker, smoked previously or use smokeless tobacco Yes No 52. Often unhappy or depressed Yes No 53. FEMALE - taking birth control pills Yes No 54. FEMALE - pregnant Yes No 55. MALE - prostate disorders Yes No Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, and or vitamins taken within the last two yearsPlease advise us in the future of any change in your medical history or any medications you may be taking. Patient’s SignatureDate MM slash DD slash YYYY Doctor’s SignatureDate MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
