Welcome to the Office of Dr. Christopher Parker

Patient Registration and Health History

Please fill out the registration form to the best of your knowledge.

All patient information is confidential

P A T I E N T

Patient First Name: M.I.

Patient Last Name:

Sex: male female Date of Birth (M/D/Y): Age:

Social Security:

Street:

City State:

Zip

Home Tel: Bus. Tel: Ext.

Dentist:

Physician:

Who told you about our office?:

Have you ever been a patient in our practice: Yes No

Method of Personal Payment: Cash Check Credit Card

Father's First Name: M.I.

Father's Last Name:

Home Tel: Bus. Tel: Ext.

Mother's First Name: M.I.

Mother's Last Name:

Home Tel: Bus. Tel: Ext.

A C C O U N T

Who will be responsible for your account? Self Spouse Father

Mother Other

Name:

Social Security:

Home Tel: Street:

City State: Zip

Employer: Tel:

I N S U R A N C E

Student: Full Time Part Time Not

School Name

School Address

Status: Married Divorced Legally Separated Widow Single

Employed: Full Time Part Time Retired Not

Do you belong to a PPO or HMO? Yes No

PRIMARY DENTAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City:

State: Zip

Phone: Social Security:

ID No.:

SECONDARY DENTAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City:

State: Zip

Phone: Social Security:

ID No.:

MEDICAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City:

State: Zip

Phone: Social Security:

ID No.:

HEALTH HISTORY

Please fill out the health history to the best of your knowledge

All patient information is confidential

Although orthodontists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's visit:

YES NO

Are you in good health:

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Date of last visit:
If so, for what are you being treated?

Have you had any illness, operation or been hospitalized in the past five years?

Do you have a heart valve replacement or vascular graft?

If so describe where:

Have You Had or Do You
Currently Have Yes No Have You Had or Do You
Currently Have Yes No

Rheumatic fever? Gallbladder trouble?

Damaged heart valves/mitral valve prolapse? Fainting spells?

Heart murmur? Convulsions, epilepsy?

High blood pressure? Stroke?

Low blood pressure? Thyroid trouble?

Chest pain, angina? Diabetes?

Heart attack(s)? Low blood sugar?

Irregular heart beat? Kidney trouble?

Cardiac pacemaker? Are you on dialysis?

Heart surgery? Swollen ankles, arthritis, or joint disease?

Bronchitis, chronic cough? Stomach ulcers?

Asthma? Contagious diseases?

Hay fever / Sinus problems? Sexually transmitted diseases?

Tuberculosis? Problems with the immune system?

Emphysema? Delay in healing?

Difficult breathing
/ other lung trouble? A tumor or growth?

Do you smoke? X-Ray treatment / chemotherapy?

Blood transfusion? Chronic fatigue / night sweats?

Blood disorder such as anemia? A history of drug abuse?

Bruise easily? Eye disease / glaucoma?

Bleeding tendency
(abnormal bleed?) Mental health problems?

Jaundice, hepatitis or liver disease? Pain & Clicking of jaws when eating?

Infectious mononucleosis?

MEDICATION

Are You Now Taking... Yes No Yes No

Any kind of medicine, drugs, or pills? Have you ever taken diet pills?

Anticoagulants? Please list any other medications you are taking:

Tranquilizers?

Cortisone?

ALLERGIES

Are You Allergic To Or Had A Reaction To... Yes No Are You Allergic To Or Had A Reaction To... Yes No

Local anesthetics? Codeine or other narcotics?

Penicillin? Other medications?

Other antibiotics? Latex?

Sodium pentothal, valium, or other tranquilizers? Please list any allergies other than drug allergies?

Aspirin?