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PATIENT REGISTRATION & HISTORY
Please complete all information applicable.
q male q Female marital status: q single q married q Divorced q Widowed Have we treated any member of the family: Please list immediate family members and their ages: MEDICAL HISTORY
Please check Yes or No to any of the following which you have had or have at present.
qY qN aiDs
qY qN Diabetes
qY qN Heart Problems
qY qN Pneumonia
qY qN allergies
qY qN Dizziness
qY qN Hepatitis
qY qN Polio
qY qN arthritis
qY qN Drug addiction
qY qN High Blood Pressure
qY qN Rheumatic Fever
qY qN Artificial Implant/Valves
qY qN ear infections
qY qN Hypoglycemia
qY qN sinus Problems
qY qN Artificial Joint
qY qN epilepsy
qY qN Kidney Disease
qY qN stroke
qY qN asthma
qY qN eye Problems
qY qN Liver Disease
qY qN Ulcers
qY qN Blood Disorders
qY qN Fainting
qY qN meningitis
qY qN Valley Fever
qY qN Cancer
qY qN Frequent Colds
qY qN migraine
qY qN Venereal Disease
qY qN Chemotherapy
qY qN Hay Fever
qY qN mononucleosis
qY qN Convulsions
qY qN Headaches
qY qN Pacemaker
are you taking, or have you ever taken any of the following Biophosphate drugs? if yes, please list the length of time you have been taking each one.
q Zometa q aredia q Fosamax q Boniva q actonel q skelid q Bonefos q Ostec q Didronel Others: For the following questions, check Yes or No, whichever applies. Your answers are for our records only and will be considered confidential.
1. are you in good health?.q Yes q no
2. Has there been any change in your health within the last year? . q Yes q no 4. are you under the care of a physician at this time?. q Yes q no 5. Have you had any serious illnesses or operations? . q Yes q no 6. Have you been hospitalized within the last 5 years? . q Yes q no 7. are you taking any medication at this time? . q Yes q no 8. (Woman) are you pregnant or nursing at this time? . q Yes q no 9. Have you ever been physically abused/mistreated as a child or adult? . q Yes q no 10. Please list any allergies or sensitivities (food, medication, pollens)
11. Do any of the following pertain to you as a child or as an adult? Please check: q ever fallen from bike, skates, skis, walls, trees, anything q Auto accident, motorcycle/ATV accident DENTAL HISTORY
2. Have you had any problems associated with any previous dental treatment? 3. Have you or any member of your family had orthodontic treatment?4. Please check any of the following that you have ever had or now have.
q Pain in the joint: q Left q Right q side of face; q head; q neck q Holds items in mouth (pencils/pins/nails/etc.) explain:6. What is the main reason for your visit today, and what would you like to change about your smile? Please advise us of any changes in your medical or dental history so that we can better care for you.

Source: http://www.drjaw.net/wp-content/uploads/2013/08/WEAVER-REGISTRATION-ADULT.pdf