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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: ________________