Download University of Florida College of Dentistry Department of Orthodontics

University of Florida College of Dentistry
Department of Orthodontics
Patient Registration Form
Patient Information
Patient Last Name
First Name
Middle Name
Guardian Name (if patient is 18 years or younger)
Mailing Address (include apartment number)
City
State
Employment Status (select one)
Employed
Full-time Student
ZIP code
Birthdate (mm/dd/yyyy)
Part-time Student
Home phone (with area code) Work phone (with area code)
(
)
(
)
Driver’s License Number & State
Emergency Contact
Name
Phone (with area code)
(
)
Marital status (select one)
Relationship to patient
Optional Demographic and Financial Information
This optional demographic and financial information is being asked to better understand the
patients served by the College of Dentistry. This information is used to request additional
funds from the government and other sources, to help keep the cost of dental care affordable
for our patients.
Ethnic Origin (Select one)
Asian
African American
Native Hawaiian
Caucasian/White
Pacific Islander
2
3
4
5
6
7
8
9
Gross Annual Household Income
$ _________________ Per Year
American Indian/Alaskan Native
Other (Specify) ________________________
Number in Household (Select one)
I
Hispanic
10 or more
Patient Name: _________________________________
Date: ____________________
Please answer all questions by circling the best response. Your doctor will discuss your
answers with you.
Reason for your visit: _______________________________________________________
How long have you had this condition? ___________
General Questions
Is your general health good at present?
Yes
No
Are you under the care of a physician?
Yes
No
lf so, why?
__________________________________________________________
Have you been admitted to a hospital?
Yes
No
lf so, why?
__________________________________________________________
Surgical History
Have you had previous operations?
Yes
No
Please describe __________________________________________________________
Heart Conditions
Heart Attack/MI
Angina/Chest Pain
High Blood Pressure
Prosthetic Heart Valve
Congestive Heart Failure
Heart Bypass/Stent Surgery
Congenital Heart Defect
Pacemaker/Defibrillator
Infective Endocarditis
Heart Palpitations
Irregular Heart Beat
Rheumatic Heart Disease
Breathing Problems
Asthma
Tuberculosis
Sleep Apnea
Bronchitis/Emphysema/
COPD
Cough
Shortness of Breath
Pneumonia
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes No
Yes No
Yes No
Yes
Yes
Yes
Yes
No
No
No
No
Endocrine Problems
Diabetes
Thyroid Disorders
Blood Conditions
Anemia
Sickle Cell Disease
HIV disease/AIDS
Bleeding disorders
(e.g. Hemophilia/on Coumadin)
Warfarin Treatment
Bruising Easily
Head, Eyes, Ears, Nose & Throat
Frequent Headaches
Jaw Joint/TMJ Popping,
Catching, Pain
Glaucoma
Sinus or Nasal Problems
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Digestive Problems
Hepatitis/Jaundice
Liver Disease
GERD/Reflux/Ulcers
Yes No
Yes No
Yes No
Nervous System Problems
Stroke/TIA/Mini-Stroke
Yes No
Epilepsy/Seizure Disorder
Yes No
Neuropathy/Nerve Pain
Yes No
Psychiatric Problems
Depression
Panic/Anxiety Disorder
Other Psychiatric or
Emotional Disorders
Yes No
Yes No
Social History
Smoking/Tobacco Use
Yes No
Alcoholic Beverages
Yes No
Recreational (Street) Drugs Yes No
Allergies
Pain Medicine(s)
Penicillin/Amoxicillin
Other Antibiotics
Local Anesthetics
Other Medicines
Latex/Glove Powder
Environmental/Seasonal
Other Allergies Yes No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes No
List Allergic Reactions: __________________
Other Problems
Renal/Kidney
Prostate Disease
Organ Transplant
Cancer/Tumors
Radiation/Chemotherapy
Arthritis
Artificial Joint/Joint
Replacement
Any other problems?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes No
Yes No
Describe: _______________________
________________________________ ________________________________
For Women Only
Are you nursing?
Are you/could you be
pregnant?
Family History
Cancer
Arthritis
Heart Disease
Hypertension
Anesthesia Complications
Yes No
Yes No
_____________________________________
_____________________________________
Medications
Anticoagulants
(blood thinners)
Aspirin
Coumadin
Plavix
Bisphosphonates(Reclast,
Fosomax, Actonel,
Boniva, Aredia, Zometa)
Other Medicines
Steroids
Birth Control Pills
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Other Drugs (List Drug Name & Dose):
_____________________________________
_____________________________________
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
_____________________________________
Supplements (Diet Supplements, Natural or
Herbal Vitamins):
_____________________________________
_____________________________________
_____________________________________
Signature: _________________________________________________ Date: ________________