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Microsoft word - new-patient-registration-form
BestCare Family Dental
88-09 Northern Boulevard
Jackson Heights, N.Y. 11372
Emergency Contact: Name ___________________
Dental Insurance: Phone _____________________
If you are completing this form for another person, what is your relationship to that person? ___________________ Referred by ___________________________________________
HAVE YOU HAD:
Are you in good general health?
Are you now taking any drugs or medications?
(Novocaine or Xylocaine) by a dentist or doctor?
Have you ever had any adverse reaction to either
Do you take aspirin products or anti-inflammatory
PLEASE LIST ALL PREVIOUS SURGERIES AND DATES:
Have dentures, false teeth, caps or bridges
Have any contagious or infectious condition
NO YES Are you happy with your smile?
NO YES Are you interested in straighter teeth (Invisalign)?
NO YES Would you like to change the whiteness of your teeth and/or fillings?
NO YES Are you interested in replacing missing teeth?
NO YES Do your gums bleed?
NO YES Do you have bad breath/unpleasant taste?
NO YES Do you have swelling/lumps in your mouth?
NO YES Are your teeth sensitive to cold/hot/sweets/pressure?
NO YES Do you clench/grind your teeth?
NO YES Have you had an unfavorable dental experience? Please explain: __________________________________________
____________________________________________________________________________________________________________ Chief Dental Complaints ______________________________________________________________________________________
The above information is strictly confidential
I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
For completion by the dentist.
Comments on patient interview concerning medical history:
Significant findings from questionnaire or oral interview: ____________________________________________________________
Signature of Dentist
Medical History Update:
Congeneric and (Essentially) Tau-Equivalent Estimates of Score Reliability: What They Are and How to Use Them Educational and Psychological Measurement The online version of this article can be found at:http://epm.sagepub.com/cgi/content/abstract/66/6/930 can be found Educational and Psychological Measurement Additional services and information for (this article cites 4
Health Insights Today A SERVICE OF CLEVELAND CHIROPRACTIC COLLEGE CAM in Review When reading reports on new research, it is important to remember that no single study should be seen as providing the whole truth. The following reports offer helpful clues but in most cases further research is needed before firm conclusions can be drawn. Multicenter Study Finds Acupuncture Effec