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
    iodine
    red dye
    chlorhexidine (CHX)
    metals (nickel, gold, silver) latex
    nuts
    fruit
    milk
    other
  3. heart problems, or cardiac stent within the last six months  
  4. history of infective endocarditis  
  5. artificial heart valve, repaired heart defect (PFO)  
  6. pacemaker or implantable defibrillator  
  7. orthopedic or soft tissue implant (e.g., joint replacement, breast implant)  
  8. heart murmur, rheumatic or scarlet fever  
  9. high or low blood pressure  
  10. a stroke (taking blood thinners)  
  11. anemia or other blood disorder  
  12. prolonged bleeding due to a slight cut (INR>3.5)  
  13. pneumonia, emphysema, shortness of breath, sarcoidosis  
  14. chronic ear infections, tuberculosis, measles, chicken pox  
  15. breathing problems (e.g., asthma, stuffy nose, sinus congestion)  
  16. sleep problems (e.g., sleep apnea, snoring, insomnia, restless sleep, bedwetting)  
  17. kidney disease  
  18. liver disease or jaundice  
  19. vertigo (e.g., ”the room is spinning”)  
  20. thyroid, parathyroid disease, or calcium deficiency  
  21. hormone deficiency or imbalance (e.g., polycystic ovarian syndrome)  
  22. high cholesterol or taking statin drugs  
  23. diabetes  
  24. stomach or duodenal ulcer  
  25. digestive or eating disorders (e.g., gastric reflux, bulimia, anorexia, celiac disease, Crohn’s disease, or any inflammatory bowel disease)  
  26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g., bisphosphonates)  
  27. arthritis or gout  
  28. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)  
  29. glaucoma  
  30. contact lenses  
  31. head or neck injuries  
  32. epilepsy, convulsions (seizures)  
  33. neurologic disorders (e.g.,Alzheimer's disease, dementia, prion disease)  
  34. viral infections (e.g., cold sores) bacterial infections (e.g., Lyme disease)  
  35. any lumps or swelling in the mouth  
  36. hives, skin rash, hay fever  
  37. STI/STD/HPV  
  38. hepatitis  
  39. HIV/AIDS  
  40. tumor, abnormal growth  
  41. radiation therapy  
  42. chemotherapy, immunosuppressive medication  
  43. difficulties with stress management  
  44. psychiatric treatment, antidepressants, mood stabilizing medications  
  45. concentration problems or ADD/ADHD  
  46. alcohol/recreational drug use  
  47. presently being treated for any other illness  
  48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)  
  49. taking medication for weight management  
  50. taking dietary supplements, vitamins, and/or probiotics  
  51. often exhausted or fatigued  
  52. experiencing frequent headaches or chronic pain  
  53. a smoker, smoked previously or other (e.g., smokeless tobacco, vaping, e-cigarettes, and cannabis)  
  54. considered a touchy/sensitive person  
  55. often unhappy or depressed  
  56. taking birth control pills  
  57. currently pregnant  
  58. 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, 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 sometimes or are they ever uncomfortable when brushing or flossing?  
  2. Have you ever had or been told you have gum loss, gum disease, or bone loss between your teeth?  
  3. Have you ever noticed an unpleasant taste, odor in your mouth, or swollen and puffy gums?  
  4. Is there anyone with a history of periodontal disease in your family?  
  5. Have you ever experienced gum recession, or can you see more of the roots of your teeth?  
  6. Have you ever had any teeth become loose on their own (without an injury), or feel them move when chewing?  
  7. Have you experienced a burning, painful sensation, or metallic taste in your mouth?  
Tooth Structure
Yes
No

No to All
  1. Have you had any cavities within the past 3 years?  
  2. Does the amount of saliva in your mouth seem too little, not enough, or do you have difficulty swallowing or chewing 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 do you 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 a toothache or cracked filling?  
  7. Do you frequently get food caught between any teeth?  
Bite And Jaw Joint
Yes
No

No to All
  1. Does your jaw joint ever have pain, sounds (popping, cracking), or experience limited opening or locking?  
  2. Do you feel like you need to pull your lower jaw back, or feel that it is being pushed back when you try to bite your back teeth together?  
  3. Do you avoid or have difficulty chewing gum, raw 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 more than one bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together better?  
  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 / nighttime or ever make them sore?  
  11. Do you have any problems with sleep (i.e., restlessness or teeth grinding), 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 mouth (smile, lips, teeth, gums) that you would like to change (color, spaces, size, shape, display)?  
  2. Have you ever bleached (whitened) 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?