2470 S. Western Avenue Suite A San Pedro 90732 T 424.224.7300
Dental Registration and Health History
Patients Name ____________________________________ How do you prefer to be addressed?________________________________
Mailing Address ___________________________________City___________________________State___________Zip________________
Sex: M F Age:___________ Birth Date:___________ Single Married Widow Separated
Divorced SS#______________________
Home Phone Number:___________________________________ Work phone Number:________________________________________
Who may we thank for referring you?______________________________________________________________________
If the person responsible for this patient’s account is different from the patient or if this patient is a minor,
the responsible party must fill out the section below. Otherwise, Please skip to the section titled “Insurance
Information”
Name of responsible party ___________________________ Relationship to Patient_________________________________
Mailing Address ___________________________________City___________________________State___________Zip________________
Sex: M F Age:___________ Birth Date:___________ Single Married Widow Separated
Divorced SS#______________________
Home Phone Number:___________________________________ Work phone Number:________________________________________
Insurance Information
Policy Holders Name _________________ Relationship to Patient ______________ SS#________________ Zip__________
Name of Employer ___________________ Employee Address ________________________________State______________
Insurance Co. ________________________Group# _______________________ Address____________________________
Secondary Insurance Information
Policy Holders Name _________________ Relationship to Patient ______________ SS#________________ Zip__________
Name of Employer ___________________ Employee Address ________________________________State______________
Insurance Co. ________________________Group# _______________________ Address____________________________
Answers to the following questions are for our records only and will be considered confidential.
1. Have you or any member of your family been seen by us before?
o Yes o No
If yes, which family member (s)? _____________________________________________________________
2. Date of last physical examination ___________________________ Physician’s Name ____________________________
3. Date of last physical examination ___________________________Date of last dental x-rays_______________________
4. Previous Dentist’s Name ___________________________________ City/State___________________________________
5. Are you having pain or discomfort at this time?
o Yes o No
6. Do you feel nervous about having dental treatment?
o Yes o No
7. Have you ever had a bad experience in a dental office?
o Yes o No
8. Is there anything you dislike about your smile?
o Yes o No
9. Is there anything you would like to speak with the Doctor about in private?
o Yes o No
10. Have you been a patient in the hospital during the past two years?
o Yes o No
11. Have you been under the care of a medical doctor during the past two years?
o Yes o No
12. Have you taken any medications or drugs in the past two years?
o Yes o No
13. Are you taking any vitamins, herbal supplements or “cures”?
o Yes o No
14. Have you ever had any excessive bleeding requiring special treatment?
o Yes o No
Allergies
o
Yes
Aspirin
o Yes
Barbiturates
o Yes
Codeine
o Yes
Iodine
o Yes
latex
Medications
o No
o No
o No
o No
o No
Local Ane o Yes o No
Penicillin o Yes o No
o Yes o No
Sulfa
o Yes o No
Metals
Other:_______________
Please list medications you are currently taking:
_______________________________________________
_______________________________________________
_______________________________________________
Place a mark on yes or no to indicate if you have had any of the following:
Chest Pain
Heart Failure
Hives or skin rash
o Yes o No
o Yes o No
Shortness of Breath
o Yes o No
Ulcers
o Yes o No
Alcoholism
o Yes o No
Heart Disease or Attack
o Yes o No
Mental Retardation
o Yes o No
Herpes
o Yes o No
Angina Pectoris
o Yes o No
Emphysema
o Yes o No
Glaucoma
o Yes o No
Heart Problems
o Yes o No
Fainting or dizzy spells
o Yes o No
*Steroid Treatment
o Yes o No
Liver Disease
o Yes o No
Eating Disorder
o Yes o No
Arthritis
o Yes o No
Heart Surgery
o Yes o No
Epilepsy or siezures
o Yes o No
*Any type of implant
o Yes o No
High Blood Pressure
o Yes o No
Persistent Cough
o Yes o No
Dentures or Partials
o Yes o No
*Heart Murmur
o Yes o No
Tuberculosis (TB)
o Yes o No
Birth defects
o Yes o No
*Rheumatic Fever
o Yes o No
Asthma
o Yes o No
HIV Positive, ARC, AIDS o Yes o No
Psychiatric treatment
o Yes o No
*Congenital Heart Problems
o Yes o No
Hay fever
Sickle Cell Disease
o Yes o N
Hepatitis A (Infectious)
o Yes o No
Use of tobacco products o Yes o No
Sinus trouble
o Yes o No
Hepatitis B (Serum)
o Yes o No
Bruise easily
o Yes o No
*Artificial joints
o Yes o No
Hepatitis C or other
o Yes o No
Jaundice
o Yes o No
Thyroid Disease
o Yes o No
Heart pacemaker
o Yes o No
Heart Surgery
o Yes o No
Anemia
o Yes o No
Stroke
o Yes o No
Kidney trouble
o Yes o No
Blood transfusion
o Yes o No
Drug addiction
o Yes o No
Hemophilia
o Yes o No
*Any type of transplant
o Yes o No
Cold Sores
o Yes o No
Diabetes
o Yes o No
*Mitral Valve Prolaps
o Yes o No
Radiation Therapy
o Yes o No
Chemotherapy
o Yes o No
o Yes o No
Cancer (type:
* Antibiotic pre-medication may be required prior to your appointment.
Have you ever experienced any of the following problems with your jaw:
Clicking
o Yes o No
Pain in or around ears?
o Yes o No
Difficulty opening or closing
o Yes o No
Difficulty chewing
o Yes o No
Do you have history of trauma to your jaw?
o Yes o No
Have you ever been diagnosed with TMJ/TMD
o Yes o No
o Yes o No
)
o Yes o No
Do you have any of the problems listed below?
Swelling
Bleeding Gums
Bad Taste
Loose Teeth
o Yes
o Yes
o Yes
o Yes
o No
o No
o No
o No
Sensitive to:
Hot
Cold
Biting/Pressure
Sweets
o Yes
o Yes
o Yes
o Yes
o No
o No
o No
o No
Other:___________________________________
Do you have any sores, lumps or growths in or near your mouth? o Yes o No
Have you ever had difficult extraction’s in the past?
o Yes o No
Have you ever had prolonged bleeding following extraction’s?
o Yes o No
Are there now any growths or sores in or around your mouth?
o Yes o No
Have you ever been told you have gum problems? o Yes o No
Have you ever needed to see a periodontist?
o Yes o No
Do you now have bleed gums or other gum condition o Yes o No
Do you habitually clench or grind your teeth during the day or night?
o Yes o No
Problems with bad breath? (Halitosis)
o Yes o No
Do you have trouble chewing?
is there aanything related to your medical
dental history that you have not indicated above?
if yes, please explain:_________________________________
I certify that I have read and understand the above information to the best of my knowledge. the above questions have been accurately
answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such
dental care to this party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist
or dental group insurance benefits otherwise pay able to me. I understand that my dental insurance carrier may pay less than the actual
bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.