Dr. S. Sharma – Periodontics & Dental Implant Surgery │ Registration and Medical History:

Given Name: (first) (middle)(last)
Preferred Name: Birthdate: DDMonthYY
Gender: Height: Weight:
Home Address:City:Postal Code:
Home Phone:Work Phone:
Cell Phone: E-mail:
Preferred Method of Contact:Occupation:
Referred by:
Dentist’s Name:Phone:
Physician’s Name: Address:
Phone: City: Postal Code:
 
Insurance Company: Group/Policy Number:
Certificate ID#: Policy Holder:
Policy Holder Birthdate: DDMonthYY
 
Secondary Insurance Company: Group/Policy Number:
Certificate ID#: Policy Holder:
Policy Holder Birthdate: DDMonthYY
 
1. Have you been under the care of a medical doctor during the past three years? .........Yes No
2. Please list medications and dosages taken presently:
3. Are you aware of an allergic (or adverse reaction) to any medication or substance?... Yes No
If Yes, please list:
4. Have you been a patient in the hospital in the past two years? ................................... Yes No
If Yes list procedure(s):
5. Indicate which of the following you have had, or have at present. Select “yes” or “no” to each item.
Heart (Surgery, Disease, Attack)………......... Yes No
Heart Murmur requiring antibiotic prophylaxis. Yes No
High or Low Blood Pressure…………..…........ Yes No
Rheumatic Fever……………................……… Yes No
Chest Pain………………………….……..……. Yes No
Artificial Heart Valve………….…….…. .…….... Yes No
Psychiatric/psychological care...............……. Yes No
Depression……………………………...….……. Yes No
Stroke……………………………………..…….   Yes No
Neurological Disorders………………………...   Yes No
Epilepsy or Seizures……………………………   Yes No
Diabetes ………………….……………..…….… Yes No
Thyroid Problems………………………………… Yes No
Liver Disease……………………….........………. Yes No
Hepatitis A, B or C ……………..………..……… Yes No
Kidney Disease …………………………………   Yes No
Glaucoma ……………………………….………    Yes No
Artificial Joints (hip, knee, etc)………….………  Yes No
Arthritis………..……………….………....………   Yes No
Osteoporosis…………………………………… .   Yes No
Cancer ………………………….…………………. Yes No
Radiation Therapy…………………..........……… Yes No
Chemotherapy…………………………….………. Yes No
Cortisone Medicine ……..……………….……….  Yes No
Hemophilia………………………….........……… . Yes No
Sickle Cell Disease……………………….……… Yes No
Emphysema …………………………………....    Yes No
Asthma …………….…………….……..…………. Yes No
Sleep Apnea …………………………….……….   Yes No
Do you wear a CPAP at night? …………..……… Yes No
A.I.D.S …………………………..…………………. Yes No
H.I.V. Positive………………………....………...... Yes No
6. Do you have or have had any disease, condition or problem not listed above? .....Yes No
If Yes, please list:
7. Do you smoke? Yes     No
If yes how many packs/day:for how many years:?
If you have quit smoking when?:
How much did you smoke and for how long?:
8.For Women.
Are you Pregnant?  Yes , Months;  No
Are you Nursing?  Yes  No
Are you Menopausal?  Yes  No
 
Dental Information
Do You
Have dental pain or problems now?       Yes No
Fear the dentist or dental treatment?     Yes No
Grind or clench your teeth?                   Yes No
Have Pain on opening/closing mouth?   Yes No
Have bleeding gums?                             Yes No
Do you have dental implants?                Yes     No
Have You
Had problems with dental anaesthetic?                Yes No
Had prolonged bleeding after tooth extraction?   Yes No
Noticed Shifting of your teeth?                             Yes No
Ever been told you have gum disease?              Yes No
Ever had gum surgery?                                      Yes No
How often do you brush your teeth per day? Yes:
How often do you floss your teeth per day?:
Any other dental condition that I should be aware of? Yes     No
If Yes, then please describe:
Date of most recent dental cleaning?:
 
SCHEDULING
We reserve appointment times for you specifically and do our very best to be on schedule. We require 2 business days notice for cancellation or change of appointment. Changes or cancellations with less notice than 2 business days are subject to a $100 fee.
 
INSURANCE
Please remember that your insurance plan is an agreement between yourself and your insurance company. Most plans do not cover all costs of care, particularly specialty services. We are happy to complete forms for your insurance company however, the patient or guardian is responsible for all fees incurred and they are due at the time service is provided.
 
*Please turn off cell phones and pagers so that we might have your uninterrupted attention during your visit.