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Patient Registration Form Harmony Patient Registration Form General Information: Today’s Date:_____________________ First name:__________________________ Last name:____________________________________ Preferred Name/Nickname_____________________________________________________________ SSN:________________________________ Date of Birth:______/______/_______ Home phone:________________________ Work phone:__________________________________ Mobile phone:_______________________ Email address:_________________________________ Home address:_______________________________________________________________________ Is billing address same as home address? Yes No If no, please provide billing address:____________________________________________________ Emergency contact person:____________________________________________________________ Phone number of the emergency contact person:_________________________________________ How did you hear about us?___________________________________________________________ Whom may we thank for referring you?__________________________________________________ Preferred contact method: Cell phone Home phone Work phone Email Text message Dental Insurance (If you have already provided this information, please skip) Policyholder’s name:__________________________________________________________________ Policyholder’s date of birth:____________________ Policyholder Relationship to patient: Self Spouse Child Other_______________ Policyholder’s Address (if different than patients):_________________________________________ ____________________________________________________________________________________ Name of insurance company:__________________________________________________________ Policy or Subscriber ID#:________________________________ Group #:______________________ Do you have more than one dental insurance? Yes No If so, please provide the additional information: Policyholder’s name:__________________________________________________________________ Policyholder’s date of birth:____________________ Policyholder Relationship to patient: Self Spouse Child Other_______________ Name of insurance company:__________________________________________________________ Policy or Subscriber ID#:________________________________ Group #:______________________ Medical History: Date of last physical exam:_____________________________________________________________ Name of your primary physician:________________________________________________________ Are you now under a physician’s care for a particular problem? Yes No If yes, please describe:________________________________________________________________ _____________________________________________________________________________________ Have you ever had any serious illness, operations or hospitalizations? If so , please describe:_________________________________________________________________ Do you have or have you ever had any of the following (check all that apply)? ❑ AIDS/HIV Positive ❑ Convulsions ❑ Genital Herpes ❑ Leukemia ❑ Alzheimer disease ❑ Coronary artery ❑ Glaucoma ❑ Liver Disease ❑ Anaphylaxis Disease ❑ Heart Attack ❑ Low blood ❑ Anemia ❑ Cortisone ❑ Heart Murmur Pressure ❑ Angina Medicine ❑ Heart Palpitations ❑ Lung Disease ❑ Anxiety ❑ Drug Addiction ❑ Heart Surgery ❑ Mitral Valve ❑ Arthritis ❑ Depression ❑ Hemophilia Prolapse ❑ Artificial Heart ❑ Diabetes ❑ Hepatitis A ❑ Osteoporosis Valve ❑ Dizziness ❑ Hepatitis B ❑ Pacemaker ❑ Artificial Joint ❑ Dripping ❑ Hepatitis C ❑ Parathyroid ❑ Asthma ❑ Easily winded ❑ Herpes Disease ❑ Bleeding disorder ❑ Emphysema ❑ High Blood ❑ Pneumonia ❑ Bleeding tendency ❑ Epilepsy Pressure ❑ Poor ❑ Blood disease ❑ Excessive Thirst ❑ High Cholesterol Concentration ❑ Blood transfusion ❑ Fainting ❑ Hip Replacement ❑ Poor Memory ❑ Bronchitis ❑ Frequent diarrhea ❑ Hives or Rash ❑ Psychiatric Care ❑ Bruise easily ❑ Frequent ❑ Hypoglycemia ❑ Radiation ❑ COPD Headaches ❑ Irregular Heartbeat Treatment for head ❑ Chemotherapy ❑ Frequent migraine ❑ Irritability/Anger and neck region ❑ Chest pain ❑ Frequent Nasal ❑ Itchy or Dry Skin ❑ Radiation ❑ Chronic cough Problems ❑ Jaundice Treatment for ❑ Cold Sores/Fever ❑ Frequent Nausea ❑ Jaw Joint Pain cancer Blisters ❑ Gastric Reflux ❑ Kidney Disease ❑ Congenital Heart ❑ General Run Down ❑ Knee Surgery/ Disease Feeling Replacement ❑ Recent Weight ❑ Shingles ❑ Stomach Ulcers ❑ Tumors or Growth Loss ❑ Shortness of or Colitis ❑ Venereal Disease ❑ Renal Dialysis Breath ❑ Stomach/Intestinal ❑ Heart Palpitations ❑ Rheumatic Fever ❑ Sickle Cell Disease Disease ❑ Rheumatic Heart ❑ Sinus Problems ❑ Stroke Any disease, drug or Disease ❑ Skin Rash ❑ Swelling of Limbs transplant operation ❑ Scarlet Fever ❑ Sleep Apnea ❑ Thyroid Disease that has depressed ❑ Seizures ❑ Spina bifida ❑ Tonsillitis your immune system ❑ Severe Coughing ❑ Tuberculosis Are you allergic to any of the following? ❑ Acrylic ❑ Ibuprofen ❑ Metal ❑ Sedatives ❑ Aspirin ❑ Iodine ❑ Morphine ❑ Sulfa Drugs ❑ Codeine ❑ Latex ❑ Penicillin ❑ Tylenol ❑ Demerol ❑ Local Anesthetics ❑ Plastics If allergic to other, please specify:____________________________________________________________ Have you ever taken Phen-Fen or Redux? Yes No Have you ever taken Fosamax, Boniva, Actonel or any medications containing bisphosphonates? Yes No Check each alternative treatments (if any) you have tried: ❑ Acupuncture ❑ Hypnosis ❑ Meditation ❑ Biological/Holistic ❑ IV(chelation)therapy ❑ Naturopathic Medicine Dentistry ❑ Infrared sauna ❑ Reiki ❑ Chinese Medicine ❑ Iridology ❑ Rolfing ❑ Chiropractic ❑ Light therapy ❑ Yoga ❑ Homeopathy ❑ Massage therapy For Women: Have/Are you? Taking oral contraceptive? Yes No Nursing? Yes No Trying to get pregnant? Yes No Pregnant? Yes No Had a history of abnormal pap smear? Yes No Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals: ______________________________________________________________________________ ______________________________________________________________________________ Do you usually take any antibiotic medication prior to dental treatment? Yes No Is there anything you wish to speak about in private with the doctor? Yes No Dental History: When was your last dental cleaning?______________________________________________ How often have you had dental cleanings in the past? Every 3 months Every 4 months Every 6 months Once a year Every few years What made you leave the previous dentist?________________________________________ Has any dental treatment been recommended to you that you have not had done? ______________________________________________________________________________ Have you been diagnosed with periodontitis (gum disease)? Yes No Have you had deep cleaning (scaling and root planing procedure)? Yes No Are you concerned about bad breath? Yes No How often do you floss? Never Rarely Weekly 2-3 times a week 3-4 times a week 4-5 times a week Daily What type of toothbrush do you use? Hard bristle Soft bristle Manual Battery operated Electric From 1-10, how do you rate your smile? 1 being worst and 10 being best. 1 2 3 4 5 6 7 8 9 10 Have you bleached/whitened your teeth? Yes No Are you interested in whitening your teeth? Yes No Are you interested in learning more about mercury in silver amalgam fillings? Yes No Do you have any medical or dental problems that you think the doctor should know about? If yes, please describe:______________________________________________________________ __________________________________________________________________________________ Have you had orthodontic (Braces/Invisalign) treatment? Yes No Are you interested in orthodontic treatment? Yes No Do you have any sensitivity to the following stimulations? Chewing/Biting Sweets Hot Cold Do you have or have you ever had any of the following: ❑ Bleeding gum ❑ Neck Pain ❑ Clicking or Popping in Jaw ❑ Clenching ❑ Shifting in Bite ❑ Difficulty opening or ❑ Grinding ❑ Sore Gum Closing Jaw ❑ Jaw pain ❑ TMJ Problems ❑ Headaches Does food constantly get stuck between certain teeth in your mouth? Yes No Has the fear of discomfort kept you from regular dental visits? Yes No What prompted you to seek dental care at this time?_________________________________________ ________________________________________________________________________________________ Social History: How often do you exercise? Everyday 5-6 times a week 4-5 times a week 3 times a week 1-2 times a week A couple of times a month Never How often do you drink alcohol? Never Daily Weekly Monthly A few times a week Are you on a special diet? Yes No Do you use any of the following? Electric Cigarettes Cigarettes Controlled substances Chewing tobacco None Sleep History: Have you snored or been told that you do? Never Rarely Sometimes Often Have you had choking or shortness of breath sensations at night? Never Rarely Sometimes Often Average hours of sleep at night: Less than 3 hours 3-4 hours 4-5 hours 5-6 hours 6-7 hours 7-8 hours More than 8 hours Have you had morning fatigue or fogginess or woken up feeling unrefreshed? Never Rarely Sometimes Often Have you woken up with a headache? Never Rarely Sometimes Often Have you had chronic sleepiness, fatigue or weariness that you cannot explain? Never Rarely Sometimes Often Have you woken up during sleep? Never Rarely Sometimes Often Have you fallen asleep during the day, particularly when not busy? Never Rarely Sometimes Often Have you fallen asleep reading or watching television? Never Rarely Sometimes Often Have you fallen
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