PATIENT REGISTRATION

PATIENT REGISTRATION

New Patient Registration Mississauga

Primary insurance information:

Secondary Insurance info:

Medical History

Are you under a physician care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on special diet?
Are you on special diet?

Women: Are you...

Are you allergic to the following?
Other?

Do you have, or you had, any of the following?

Aids/HIV Positive
Excessive Thirst
Mitral Valve Prolapse
Alzheimer Disease
Fainting Spells/Dizziness
Osteoporosis
Anaphylaxis
Frequent Cough
Pain in Jaw Joints
Anemia
Frequent Diarrhea
Parathyroid Disease
Angina
Frequent Headaches
Psychiatric care
Arthritis/Gout
Genital Herpes
Radiation Treatment
Artificial Heart Valve
Glaucoma
Recent Waight Loss
Artificial Joint
Hay Fever
Renal Dialysis
Asthma
Heart Attack/Failure
Heart Attack/Failure
Blood Disease
Heart Murmur
Rheumatism
Blood Transfusion
Heart Pacemaker
Scarlet Fever
Breathing problems
Heart Trouble/Disease
Shingles
Bruise Easily
Hemophilia
Sickle Cell Disease
Cancer
Hepatitis A
Sinus Trouble
Chemotherapy
Hepatitis B or C
Spina Bifida
Chest Pains
Herpes
Stomach/Intestinal Dis.
Cold Sores/Fever Blisters
Hight Blood Pressure
Stroke
Congenital Heart Disorder
High Cholesterol
Swelling of Limbs
Convulsions
Hives or Rush
Thyroid Disease
Cortisone Medicine
Hypoglycemia
Tonsillitis
Diabetes Hemophilia
Irregular Heartbeat
Tuberculosis
Drug Addiction
Kidney Problems
Tumors or Growths
Easily Winded
Leukemia
Ulcers
Emphysema
Liver Disease
Venereal Disease
Epilepsy or Seizures
Low Blood Pressure
Yellow Jaundice
Excessive Bleeding
Lung Disease

Have you ever had any serious illness not listed above?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.