Professional Documents
Culture Documents
PATIENT REGISTRATION
Chart
ID:
ID:
First Name:
Last Name:
Patient Is:
Policy Holder
Middle Initial:
Responsible Party
Last Name:
Middle Initial:
Address:
State
City :
Home Ph:
Zip
Relationship To Patient
Work Ph:
Birth Date:
Ext:
Cell
Soc Sec:
Drivers Lic:
Primary Insurance Policy Holder
Patient Information
Address:
City:
Home Phone:
Sex:
Zip:
State:
Work Phone:
Male
Female
Is Patient Minor
Birth Date:
Age:
Yes
No
Ext:
Marital Status:
Married
Single
Cellular:
Divorced
SSN:
E-mail:
Separated
Partnered Far
Drivers Lic:
Employed
Student
Additional Comments:
Other
Employer/School Name
Employer/School Address
Primary Insurance Information
Relationship to Insured:
Insured's Name
Insured's Employer
Ins. Co
Group#
Widowed
Plan
Member/Policy#
Phone#
Relationship to Insured
Insured's Employer:
Inc. Co
Insured SSN:
Group#
Member/Policy#
Plan
Dental History
Sensitivity to
Yes
Cold
Neck Pain
Earaches
Braces
Sweet
Yes
No
Headache
Phone#
Pressure
UR
Where ?
No
Yes
No
Bad Breath
Partial Dentures
Ear Ringing
LR
UL
Grinding,clenching teeth
Dentures
Tipped,shifting teeth
Dry Mouth
Difficulty in chewing
Make it straighter
LL
Yes
No
Make it whiter
How much?
Address
Phone Number
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?
Physician's name
Blood Pressure
Physician's address
Have you had any serious illness or operations
Yes
Yes
Yes
No
Due date
Cold Sores/Fever
Blisters
Congenital Heart
Disorder
Nursing?
No
Frequent Diarrhea
Yes
Yes
No
No
High Cholesterol
Yes
Yes
No
No
Yes
Rheumatic Fever
Frequent Headaches
Hives or Rash
Sleep Apnea
Genital Herpes
Hypoglycemia
Renal Dialysis
No
Anemia
Convulsions
Glaucoma
Irregular Heartbeat
Heart Surgery
Angina
Cortisone Medicine
Hay Fever
Kidney Problems
Rheumatism
Arthritis/Gout
Diabetes
Heart Attack/Failure
Leukemia
Osteoporosis
Drug Addiction
Heart Murmur
Liver Disease
Shingles
Artificial Joint
Easily, Winded
Heart Pacemaker
Scarlet Fever
Asthma
Emphysema
HIV Positive
Spina Bifida
Lung Disease
Stroke
Blood Disease
Epilepsy or Seizures
Heart
Trouble/ Disease
Hemophillia
Blood Transfusion
Excessive Bleeding
Hepatitis A
Rheumatism
Seizures
Breathing Problem
Hepatitis B or C
Pacemaker
Tonsillitis
Bruise Easily
Excessive Thirst
Fainting
Spells/Dizziness
Herpes
Thyroid Disease
Tuberculosis
Cancer
Frequent Cough
Venereal Diseases
Ulcers
Psychiatric Care
Radiation Treatment
Yellow Jaundice
Sinus Trouble
Thyroid Disease
Venereal Disease
Rheumatic Fever
Parathyroid Disease
Swelling of Limbs
Tuberculosis
HPV(Human
Stomach/Intestinal
Disease
Papilloma Virus)
Heart Lesions
Nervousness/Depression
Are you allergic or have you reacted adversely to any of the following medications?
Yes
No
Yes
No
Tetracycline
Percodan
Aspirin
Yes
Respiratory Problems
Tumors of Growths
(Congential)
No
Yes
Valium
Darvon
Latex
Codeine
Penicillin
Nitrous Oxide
Local Anesthetic
Erythromycin
Sulfa
No
Others
No
Yes
Actonel
Zometa
Aredia
Boniva
Fosamax
Herbal
No
What medications are you currently taking?
Reclast
Family Physician
Phone Number
Supplements
Consent:
The undersigned here by authorizes Doctor to take X-rays,study models,photographs,or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's
dental needs. I also authorize Doctor to perform any all forms of treatment and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I have read,
understand and agree to the above terms and conditions.
Date
Dentist Signature