DENTAL REGISTRATION AND HISTORY

PATIENT INFORMATION
DENTAL INSURANCE
Policy Holder
Relationship to Patient
Insurance Co
Group#

Is patient covered by any additional insurance?
Policy Holder
Birthdate SSN#
Relationship to Patient
Insurance Co
Group#

ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with and assign directly to Dr. Sayyar all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Relationship

Responsible Party SignaturDate
PHONE NUMBERS
Home Work Ext Spouse's Work
Best time to reach you

EMERGENCY CONTACT (specify someone who does not live in your household):
Name Relationship
Home Phone Work Phone Ext

DENTAL HISTORY Place a mark on "Yes" or "No" to indicate if you have had any of the following:
Reason for today's visit
Former Dentist: City/State
Date of Last Dental Visit / X-Ray /

Bad Breath Yes No Blisters on lips or mouth Yes No
Burning sensation on tongue Yes No Loose teeth or broken fillings Yes No
Chew on one side of mouth Yes No Mouth breathing Yes No
Cigarette, pipe, or cigar smoking Yes No Mouth pain, brushing Yes No
Clicking or popping jaw Yes No Orthodontic treatment Yes No
Dry mouth Yes No Pain around ear Yes No
Fingernail biting Yes No Periodontal treatment Yes No
Food collection between the teeth Yes No Sensitivity to cold Yes No
Foreign Objects Yes No Sensitivity to heat Yes No
Grinding teeth Yes No Sensitivity to sweets Yes No
Gums swollen or tender Yes No Sensitivity when biting Yes No
Jaw pain or tiredness Yes No Sores or growths in your mouth Yes No
Lip or cheek biting Yes No Bleeding Gums Yes No
How often do you floss? How often do you brush?

HEALTH HISTORY Place a mark on "Yes" or "No" to indicate if you have had any of the following:
Physician's Name Date of Last Visit

AIDS/HIV Yes No Emphysema Yes No Radiation Treatment Yes No
Anemia Yes No Epilepsy Yes No Respiratory Disease Yes No
Arthritis, Rheumatism Yes No Fainting or dizziness Yes No Rheumatic Fever Yes No
Artificial Heart Valves Yes No Glaucoma Yes No Scarlet Fever Yes No
Artificial Joints Yes No Headaches Yes No Shortness of Breath Yes No
Asthma Yes No Heart Murmur Yes No Sinus Trouble Yes No
Back Problems Yes No Heart Problems Yes No Skin Rash Yes No
Bleeding abnormally, with extractions or surgery Yes No Hepatitis Type Yes No Stroke Yes No
Blood Disease Yes No Herpes Yes No Swelling of Feet or Ankles Yes No
Cancer Yes No High Blood Pressure Yes No Swollen Neck Glands Yes No
Chemotherapy Yes No Jaundice Yes No Thyroid Problems Yes No
Circulatory Problems Yes No Kidney Disease Yes No Tonsillitis Yes No
Congenital Heart Lesions Yes No c Yes No Tuberculosis Yes No
Cortisone Treatments Yes No Low Blood Pressure Yes No Tumor/growth on head/neck Yes No
Cough, persistent or bloody Yes No Mitral Valve Prolapse Yes No Ulcer Yes No
Diabetes Yes No Nervous Problems Yes No Venereal Disease Yes No
Do you Wear Contact Lenses? Yes No Pacemaker Yes No Weight Loss, unexplained Yes No
Chemical Dependency Yes No Psychiatric Care Yes No Special Diet Yes No

Women
Are you Pregnant? Yes No Due Date Taking birth control pills? Yes No

MEDICATIONS/ALLERGIES
List medications you are currently taking: Aspirin Local Anesthetic
Barbiturates(Sleeping Pills) Penicillin
Codeine Sulfa
Iodine Other
Pharmacy Name Latex
Phone


UPDATES (to be filled in at future appointments)
Has there been any change in your health since your last dental appointment? Yes No
For what conditions?
Are you taking any new medications? Yes No If so, what




Patient's Signature Doctor's Signature