Central Office

Registration Form (Adult)

Personal Information
Emergency Contact
Medical History

Excellent    Good    Fair    Poor


No to All
  1. hospitalization for illness or injury
  2. an allergic reaction to
  3. aspirin
    local anesthetic
    chlorhexidine (CHX)
    metals (nickel, gold, silver) latex
  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.

Dental History

Excellent    Good    Fair    Poor

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

Personal History

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

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

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

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

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?