David J. Jones DDS
Patient Registration and Health History


Name:__________________________________________ Date:___________________________________

Address:________________________________________________________________________________

Home Phone:__________________ Work Phone:__________________Cell Phone:_____________________

Date of Birth:_____________ Social Security Number:________________Employer:_____________________


Insurance Information

Subscriber’s Name:__________________Date of Birth:_____________ Social Security #:_________________

Name of Insurance Co.:___________________________Address:___________________________________


Telephone Number:_____________________Policy Number________________________________________

To Whom Can We Send Our Thanks for This Referral?_____________________________________________

Medical History (Please Answer Each Question)

1. Are you now, or have you been under the care of a physician in the past several years?.................YES    NO

2. Have you been hospitalized within the past two years?..................................................................YES    NO

3. Are you taking any medications now, whether prescription or “over the counter”?.........................YES    NO

4. Are you allergic or had any reactions to: Penicillin Local Anesthetics ............................................YES    NO
Narcotics/Codeine Aspirin/Motrin/Advil

Please list other drug problems or allergies:____________________________________________________

Please Circle if You Have Had Any of the Following:

Heart Trouble Circulatory Problems Prosthetic Joint Respiratory Problems
Anemia Kidney Disease Ulcers HIV+/AIDS
Rheumatic Fever Radiation Treatments Arthritis Tuberculosis
Abnormal Bleeding High Blood Pressure Nervous Problems Hepatitis A/B/C
Convulsions Diabetes Sinus Problems Asthma
Thyroid Disease Mental Illness Fainting Alcoholism

6. Are you a smoker? (______pack(s) a day)................................................................................YES    NO

7. Ladies, are you pregnant?..........................................................................................................YES    NO

8. Ladies, are you nursing?............................................................................................................YES    NO


9. Are there any other medical problems we should know about?..................................................YES    NO
If yes, please explain:

 

10. Please list any medications you are currently taking:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


DENTAL HISTORY

1. How long since your last dental visit?_____________________________________________
2. What was done at that time?___________________________________________________
3. When was the last time your teeth were cleaned?____________________________________
4. Were dental x-rays taken?_____________________________________________________
5. Have you ever had any problems or complications with previous dental treatment? If so, please explain:______________________________________________________________________
6. Do you clench or grind your teeth?...............................................................................YES    NO
7. Does your jaw click or pop?........................................................................................YES    NO
8. Have you had any pain or soreness in the muscles or your face or ears?........................YES    NO
9. Does food get caught in your teeth?.............................................................................YES    NO
10. Are any of your teeth sensitive to: ?Hot? ?Cold? ?Sweets? ?Pressure?
11. Do your gums bleed or hurt?.....................................................................................YES    NO
12. How often do you brush your teeth?__________________When_______________________
13. Do you use dental floss daily?....................................................................................YES    NO
14. Are you unhappy with the appearance of your teeth?..................................................YES    NO
15. Do you feel your breath is offensive at times?.............................................................YES    NO
16. Have you had gum treatment or surgery?....................................................................YES    NO
17. Have you had orthodontic work?...............................................................................YES    NO
18. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?______________________________________________________________________