Patient Registration

Ray Dental

Patient Information
                
        
Contact Information
 
Financial Information
 
                          
Dental History
              
  
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PLEASE ANSWER YES OR NO TO THE FOLLOWING:

YES

NO

Personal History
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) 
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 reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment, or had your bite adjusted?
6. Have you had any teeth removed?
GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9. Have you ever noticed an unpleasant taste or odor in your mouth?
10. Is there anyone with a history of periodontal disease in your family?
11. Have you ever experienced gum recession?
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
13. Have you experienced a burning sensation in your mouth?
TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of the teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
20. Do you frequently get food caught between any teeth?
BITE AND JAW JOINT
21. Do you have problems with your jaw joint (pain, sounds, limited opening, locking, popping)?
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard dry foods?
24. Have your teeth changed in the last 5 year, become shorter, thinner, or worn?
25. Are your teeth becoming crooked, crowded, or overlapped?
26. Are your teeth developing spaces or becoming looser?
27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you clench your teeth in the daytime or make them sore?
30. Do you have any problems with sleep, wake up with a headache, or awareness of your teeth?
31. Do you wear or have you ever worn a bite appliance?
SMILE CHARACTERISTICS
32. Is there anything about the appearance of your teeth that you would like to change?
33. Have you ever whitened (bleached) your teeth?
34. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
35. Have you been disappointed with the appearance of previous dental work?
Medical History
              

DO YOU HAVE or HAVE YOU EVER HAD:

YES

NO

1. hospitalization for illness or injury
2. an allergic reaction to
3. heart problems, or cardiac stent within the last six months
4. heart problems, or cardiac stent within the last six monthshistory of infective endocarditis
5. ARTIFICIAL VALVE, REPAIRED HEART DEFECT (PFO)
6. pacemaker or implantable defibrillator
7. ORTHOPEDIC IMPLANT (JOINT REPLACEMENT)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to slight cut (INR>3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking stain drugs
23. diabetes (HbA1c=)
24. stomach or duodenal ulcer
25. digestive disorders
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
 

YES

NO

27. arthritis
28. autoimmune disease
29. glaucoma
30. contact lenses
31. head or neck injuries
32. epilepsy, convulsions (seizures)
33. neurological disorders (ADD/ADHD, prion disease)
34. viral infections and cold sores
35. any lumps or swelling in your mouth
36. hives, skin rash, hay fever
37. STI/STD/HPV
38. hepatitis
39. HIV/AIDS
40. tumor, abnormal growth
41. radiation therapy
42. chemotherapy, immunosuppressive medication
43. emotional difficulties
44. psychiatric treatment
45. antidepressant medication
46. alcohol/recreational drug use

ARE YOU:

47. presently being treated for any other illness
48. aware of change in your health the last 24 hours
(i.e. fever, chills, new cough, or diarrhea)
49. taking medication for weight management
50. taking dietary supplements
51. often exhausted or fatigued
52. experiencing frequent headaches
53. a smoker/smoked previously/smokeless tobacco
54. considered a touchy sensitive person
55. often unhappy or depressed
56. FEMALE - taking birth control pills
57. FEMALE - pregnant
58. MALE - prostate disorders

Drug Purpose Drug Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING

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