THPDental - Registration Form (Adult)

Personal Information

Title*

Gender*

Last Name*

First Name*

Date of Birth*

Home Address*

Home Telephone

Office Telephone

Email*

Mobile*

HKID No. / Passport No.*

Occupation

Nationality

Referred By (Please specify)

Referral Name / Tel.

Emergency Contact

Emergency Contact Person*

Relationship*

Emergency Contact Number*

Medical History

Name of Physician/and their specialty

Most recent physical examination*

Purpose*

What is your estimate of your general health?*
Excellent Good Fair Poor

DO YOU HAVE OR HAVE YOU EVER HAD*:

Yes

No

No to All

hospitalization for illness or injury

an allergic reaction to

aspirin
ibuprofen
paracetamol
acetaminophen
codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride

chlorhexidine (CHX)
metals (nickel, gold, silver) latex
nuts
fruit
other

heart problems, or cardiac stent within the last six months

history of infective endocarditis

artificial heart valve, repaired heart defect (PFO)

pacemaker or implantable defibrillator

orthopedic implant (joint replacement)

rheumatic or scarlet fever

high or low blood pressure

a stroke (taking blood thinners)

anemia or other blood disorder

prolonged bleeding due to a slight cut (INR>3.5)

pneumonia, emphysema, shortness of breath, sarcoidosis

chronic ear infections, tuberculosis, measles, chicken pox

asthma

breathing or sleep problems (e.g., sleep apnea, snoring, sinus)

kidney disease

liver disease

jaundice

thyroid, parathyroid disease, or calcium deficiency

hormone deficiency

high cholesterol or taking statin drugs

diabetes

stomach or duodenal ulcer

digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)

osteoporosis/osteopenia (i.e. taking bisphosphonates)

arthritis

autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)

glaucoma

contact lenses

head or neck injuries

epilepsy, convulsions (seizures)

neurologic disorders (ADD/ADHD, prion disease)

viral infections and cold sores

any lumps or swelling in the mouth

hives, skin rash, hay fever

STI/STD/HPV

hepatitis

HIV/AIDS

tumor, abnormal growth

radiation therapy

chemotherapy, immunosuppressive medication

emotional difficulties

psychiatric treatment

antidepressant medication

alcohol/recreational drug use

ARE YOU:

presently being treated for any other illness

aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or[ diarrhea)

taking medication for weight management

taking dietary supplements

often exhausted or fatigued

experiencing frequent headaches

a smoker, smoked previously or use smokeless tobacco

considered a touchy/sensitive person

often unhappy or depressed

taking birth control pills

currently pregnant

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.

Drug

Purpose

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

Dental History

How would you rate the condition of your mouth?*
Excellent Good Fair Poor

Previous Dentist

How long have you been a patient?

Date of most recent dental exam

Date of most recent x-rays

Date of most recent treatment (other than a cleaning)

I routinely see my dentist every*
3 mo. 4 mo. 6 mo. 12 mo. Not routinely

WHAT IS YOUR IMMEDIATE CONCERN?

Personal History

Please answer Yes or No to the following*:

Yes

No

No to All

Are you fearful of dental treatment? How fearful?

Have you had an unfavorable dental experience?

Have you ever had complications from past dental treatment?

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?

Gum And Bone

Please answer Yes or No to the following*:

Yes

No

No to All

Do your gums bleed or are they painful when brushing or flossing?

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Have you ever noticed an unpleasant taste or odor in your mouth?

Is there anyone with a history of periodontal disease in your family?

Have you ever experienced gum recession?

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Tooth Structure

Please answer Yes or No to the following*:

Yes

No

No to All

Have you had any cavities within the past 3 years?

Does the amout of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

Do you have grooves or notches on your teeth near the gum line?

Have you ever broken teeth, chipped teeth, or had toothache or cracked filling?

Do you frequently get food caught between any teeth?

Bite And Jaw Joint

Please answer Yes or No to the following*:

Yes

No

No to All

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Do you feel like your lower jaw is being pushed back when you bite your back teeth together?

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?

Are your teeth becoming more crooked, crowded, or overlapped?

Are your teeth developing spaces or becoming more loose?

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?

Do you place your tongue between your teeth or close your teeth against your tongue?

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Do you clench or grind your teeth together in the daytime or make them sore?

Do you have any problems with sleep (i.e. restlessness or teeth grindling), wake up with a headache or an awareness of your teeth?

Do you wear or have you ever worn a bite appliance?

Smile Characteristics

Please answer Yes or No to the following*:

Yes

No

No to All

Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

*I certify that the above information is complete and accurate.

Signature*

Personal Notes/Dental Notes (Official Use)

Central Office

Registration Form (Adult)