Vous êtes sur la page 1sur 3

Gainesville Dental Arts

PATIENT REGISTRATION
Chart
ID:

ID:

First Name:

Last Name:

Patient Is:

Policy Holder

Middle Initial:

Responsible Party

Responsible Party (if someone other than the patient)


First Name:

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

Responsible Party is also a Policy Holder for Patient

Secondary 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:

I would like to receive correspondences via e-mail and text-message.


Employment/School Information:

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

Ins. Co. Address

Insures Soc. Sec:

Group#

Widowed

Insured Birth Date:

Plan

Member/Policy#

Phone#

Secondary Insurance Information


Name of Insured:

Relationship to Insured

Insured's Employer:

Inc. Co

Ins. Co. Address

Insured SSN:

Insured Birth Date:

Group#

Member/Policy#

Plan

Dental History

Please check any of the following that apply to you


Hot

Sensitivity to
Yes

Cold

Teeth feel Painful

Neck Pain

Jaw joint pain

Earaches

Clicking in your jaw

Braces

Sweet

Yes

No

Headache

Phone#

Pressure

UR

Where ?

No

Yes

No

Difficulty in opening or closing your jaw


Bite your lips or cheeks frequently

Teeth or filling breaking

Bad Breath

Partial Dentures

Ear Ringing

Blisters on lip or mouth

LR

UL

If I could change my smile,I would :


Replace old crowns that don't match

Grinding,clenching teeth

Replace black metal fillings with tooth


colored restorations
Close spaces

Bleeding, swollen, irrigated gums

Repair chipped teeth

Ever worn a bite plate or other appliance

Replace missing teeth

Gums bleed while brushing or flossing.

Have a smile makeover

Dentures

Tipped,shifting teeth

Difficulty extractions in the past

Dry Mouth

Difficulty in chewing

Loose,broken teeth or broken filling

Make it straighter

Food Collection between teeth

Do you smoke or use chewing tobacco?

Sores or lumps in or near your mouth


Your last oral cancer screening
date

LL
Yes

No

Make it whiter

Your last cleaning date

How much?

For how long

Your Last complete X-Rays date

Name of the previous Dentist

Why did you leave previous dentist ?

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

Date of last visit

Blood Pressure

Physician's address
Have you had any serious illness or operations

Yes

No If yes, please describe

Have you ever had a blood transfusion

Yes

No If yes, give approximate dates

(Women) Are you pregnant?

Yes

No

Due date

Do You have, or have you had, any of the following?


Yes
No
Yes
AIDS/HIV Positive
Chest Pains
Alzheimer's Disease
Anaphylaxis

Cold Sores/Fever
Blisters
Congenital Heart
Disorder

Nursing?

No

Frequent Diarrhea

Yes

Yes

No

No

Taking birth control pills?

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

Artificial Heart Valve

Drug Addiction

Heart Murmur

Liver Disease

Shingles

Artificial Joint

Easily, Winded

Heart Pacemaker

Low Blood Pressure

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

High Blood Pressure

Venereal Diseases

Ulcers

Recent weight Loss

Psychiatric Care

Mitral Valve Prolapse

Sickle Cell Disease

Radiation Treatment

Yellow Jaundice

Pain in Jaw Joints

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

Have you ever taken any of the following medications?


Are you under a physician's care?What for?
Yes

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.

Patient Signature(Parent if child)

Date

Dentist Signature