Patient Registration

DateTime

I. PATIENT INFORMATION

First Name*

Middle Initial*

Last Name*

Age*

Date of Birth*

MonthDayYear

gender

Marital Status (Optional)

SS#*

Address*

City/State*

Home phone*

Zip Code*

Cell Phone

Work Phone*

Referred by*

How did you hear about Dr. Traub?*

E-mail Address*

Have you ever been treated by Dr. Traub before?

General Dentist

In Case of Emergency, Please Notify*

Name & Relationship

*

Phone

II. EMPLOYMENT INFORMATION

Patient's Employer

Employer Address

City/State/Zip

Phone

Spouse's Name

SS#

Spouse's Employer

Employer address

City/State/Zip

Phone

III. INSURANCE INFORMATION

Dental Insurance

Name of Carrier

Group #

Subscriber

Subscriber SS#

Birthdate

Plan

Medical or Secondary Dental Insurance

Name of Carrier

Group #

Subscriber

Subscriber SS#

Birthdate

Plan

1. Have you ever been treated for heart disease? If yes, what disease(s): Heart Attack?

*

YesNo

2. Are you being treated for any heart disease? If yes, what disease(s):

*

YesNo

3.Have you ever had Rheumantic fever?

*

YesNo

4. Do you have high blood pressure (hypertension) If yes, do you take medication? What medication?

*

YesNo

5. Do you have low blood pressure? Do you have a history of hypoglycemia?

*

YesNo

6. Are you anemic? Do you have any history of slow wound healing?

*

YesNo

7. Do you have Diabetes (sugar in blood)? If yes, do you take insulin

*

YesNo

8. Are you on any kind of special diet at this time?

*

YesNo

9. do you have Thyroid Gland Disease?

*

YesNo

10. Do you have any history of tumors or growths?

*

YesNo

11. Do you have Asthma?

*

YesNo

12. Have you ever been told or do you think that you have a bleeding disorder? If applicable, do you have any history of sickle cell?

*

YesNo

13. Have you ever had Hepatitis, liver or kidney disease?

*

YesNo

14. Do you have any history of ulcers, stomach or intestinal problems?

*

YesNo

15.Do you have a seizure disorder (Epilepsy)?

*

YesNo

17. Have you been in the hospital recently for a serious illness?

*

YesNo

16.Do you have a history of fainting?

*

YesNo

18. Have you ever had any operations? If so, what?

*

YesNo

19. Are you allergic to any drugs/medications? If yes, list them:

*

YesNo

20. Are you allergic to any non-medical substances? If yes, list them:

*

YesNo

21. Are you taking any drugs/medications right now (including birth control) If you are on multiple medications, please provide us with us with a list.

*

YesNo

22. Are you pregnant? If so, how may months? Are you taking pre-natal vitamins?

*

YesNo

23.Do you wear contact lenses?

*

YesNo

24. Do you have any history of radiation therapy?

*

YesNo

25. Do you have a cold?

*

YesNo

26. Do you have night sweats or weight loss?

*

YesNo

27. Have you ever suffered a serious head or facial injury?

*

YesNo

28. Do you have AIDS/ ARC? Or are you HIV +

*

YesNo

29. Do you have history of any other venereal disease/STD?

*

YesNo

30. Do you smoke? If yes, packs per day X how many years

*

YesNo

31. Have you ever had a difficult extraction? Dry socket?

*

YesNo

32. Have you had anything to eat/drink in the last 6-7 hours

*

YesNo

33. Do you have any history of prolonged bleeding after an extraction?

*

YesNo

34. Does your jaw pop or click when you chew?

*

YesNo

I certify that this information is true and correct to the best of my knowledge and that I will notify Dr. Traub of any changes in my health status or the information listed.

Signature*

Clear