Central Office

Registration Form (Adult)

Personal Information
Emergency Contact
Medical History

Excellent    Good    Fair    Poor

Yes
No

No to All
  1. hospitalization for illness or injury
  2. an allergic reaction to
  3. aspirin
    ibuprofen
    paracetamol
    acetaminophen
    codeine
    penicillin
    erythromycin
    tetracycline
    sulfa
    local anesthetic
    fluoride
    chlorhexidine (CHX)
    metals (nickel, gold, silver) latex
    nuts
    fruit
    other
  4. heart problems, or cardiac stent within the last six months
  5. history of infective endocarditis
  6. artificial heart valve, repaired heart defect (PFO)
  7. pacemaker or implantable defibrillator
  8. orthopedic implant (joint replacement)
  9. rheumatic or scarlet fever
  10. high or low blood pressure
  11. a stroke (taking blood thinners)
  12. anemia or other blood disorder
  13. prolonged bleeding due to a slight cut (INR>3.5)
  14. pneumonia, emphysema, shortness of breath, sarcoidosis
  15. chronic ear infections, tuberculosis, measles, chicken pox
  16. asthma
  17. breathing or sleep problems (e.g., sleep apnea, snoring, sinus)
  18. kidney disease
  19. liver disease
  20. jaundice
  21. thyroid, parathyroid disease, or calcium deficiency
  22. hormone deficiency
  23. high cholesterol or taking statin drugs
  24. diabetes  
  25. stomach or duodenal ulcer
  26. digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
  27. osteoporosis/osteopenia (i.e. taking bisphosphonates)
  28. arthritis
  29. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)
  30. glaucoma
  31. contact lenses
  32. head or neck injuries
  33. epilepsy, convulsions (seizures)
  34. neurologic disorders (ADD/ADHD, prion disease)
  35. viral infections and cold sores
  36. any lumps or swelling in the mouth
  37. hives, skin rash, hay fever
  38. STI/STD/HPV  
  39. hepatitis  
  40. HIV/AIDS  
  41. tumor, abnormal growth
  42. radiation therapy
  43. chemotherapy, immunosuppressive medication
  44. emotional difficulties
  45. psychiatric treatment
  46. antidepressant medication
  47. alcohol/recreational drug use
  48. presently being treated for any other illness
  49. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
  50. taking medication for weight management
  51. taking dietary supplements
  52. often exhausted or fatigued
  53. experiencing frequent headaches
  54. a smoker, smoked previously or use smokeless tobacco
  55. considered a touchy/sensitive person
  56. often unhappy or depressed
  57. taking birth control pills
  58. currently pregnant
  59. diagnosed with a prostate disorder

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 years.


PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Dental History

Excellent    Good    Fair    Poor


3 mo.    4 mo.    6 mo.    12 mo.    Not routinely

Personal History
Yes
No

No to All
  1. Are you fearful of dental treatment? How fearful?
  2. Have you had an unfavorable dental experience?
  3. Have you ever had complications from past dental treatment?
  4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
  5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
  6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?
Gum And Bone
Yes
No

No to All
  1. Do your gums bleed or are they painful when brushing or flossing?
  2. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
  3. Have you ever noticed an unpleasant taste or odor in your mouth?
  4. Is there anyone with a history of periodontal disease in your family?
  5. Have you ever experienced gum recession?
  6. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
  7. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
Tooth Structure
Yes
No

No to All
  1. Have you had any cavities within the past 3 years?
  2. Does the amout of saliva in your mouth seem too little or do you have difficulty swallowing any food?
  3. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
  4. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
  5. Do you have grooves or notches on your teeth near the gum line?
  6. Have you ever broken teeth, chipped teeth, or had toothache or cracked filling?
  7. Do you frequently get food caught between any teeth?
Bite And Jaw Joint
Yes
No

No to All
  1. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
  2. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
  3. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
  4. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?
  5. Are your teeth becoming more crooked, crowded, or overlapped?
  6. Are your teeth developing spaces or becoming more loose?
  7. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
  8. Do you place your tongue between your teeth or close your teeth against your tongue?
  9. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
  10. Do you clench or grind your teeth together in the daytime or make them sore?
  11. Do you have any problems with sleep (i.e. restlessness or teeth grindling), wake up with a headache or an awareness of your teeth?
  12. Do you wear or have you ever worn a bite appliance?
Smile Characteristics
Yes
No

No to All
  1. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
  2. Have you ever whitened (bleached) your teeth?
  3. Have you felt uncomfortable or self conscious about the appearance of your teeth?
  4. Have you been disappointed with the appearance of previous dental work?