Dental Registration Form

Name*

First Last

Name & Location of last dental provider:

Date of last Dental Visit:

Date of last Dental X-Rays:

My past dental experiences have been:

Eventful
Uneventful

On a scale of 1-5 my current dental health is (1-bad, 5-excellent):

Please enter a number from 1 to 5.

Do you have a specific problem that needs attention now?

Yes
No

Are you nervous or do you have anxiety about coming to the dentist or receiving dental treatment?

Yes
No

Have you had a bad experience with a dentist/dental procedure?

Yes
No

Have you ever had any complications following dental treatment?

Yes
No

If yes, please explain:

Do you/have you ever needed to premedicate prior to dental treatment?

Yes
No

Have you had a knee or hip replacement?

Yes
No

Are you pregnant or nursing?

Yes
No

Do you have bleeding gums?

Yes
No

Do you have receding gums?

Yes
No

Do you have history of gum diseases (gingivitis, periodontal disease)?

Yes
No

Have you ever needed to be numbed for a dental cleaning?

Yes
No

Do you experience dry mouth?

Yes
No

Do you have any sore, lesion, ulceration, abnormality that has not healed within 14 days?

Yes
No

Do you have persistent hoarseness, change in voice, sore throat?

Yes
No

Do you have any persistent pain, numbness in the head and neck region?

Yes
No

Do you have a mass or lump on head, neck, or inside of mouth?

Yes
No

Do you have difficulty or pain in swallowing, sensation of something stuck in the throat?

Yes
No

Do you have a persistent cough?

Yes
No

Do you experience unilateral persistent ear or jaw pain?

Yes
No

Do you have fatigue, exhaustion, unexplained weight loss?

Yes
No

Have you tested positive for Human Papillomavirus/HPV?

Yes
No

Do you have personal or family history of head & neck, oral, oropharyngeal cancer, Squamous Cell Carcinoma?

Yes
No

Is there anything you would like to change about your dental health?

Yes
No

Is there anything you would like to discuss today regarding your dental health?

Yes
No

If yes, please explain:

Consent*

I have read the above conditions of treatment I agree to their content.

I understand that I am being seen by a licensed Colorado Dental Hygienist. I understand that it is recommended that I see a licensed Colorado Dentist for dental exams yearly and that I am responsible for obtaining those exams.

Health History

Date of last physician (medical Doctor) visit:

Physicians Name

Prefix Last

Physician/ Office Phone Number

Have you ever had any of the following? Please check those that apply:

If selected "Pregnancy" above. Please enter due date here:

Do you use any of the following products:

Cigarettes
Alcohol
Cigars
Marijuana
Chewing Tobacco
Pipe Tobacco
Snuff
Vape

Have you been admitted to a hospital or needed emergency care during the past two years?

Yes
No

Are you now under the care of a physician?

Yes
No

If yes, please explain:

Do you have any health problems that need further explanation?

Yes
No

If yes, please explain:

Medication(s):

If selected "Allergies" above. Please list allergies here (including perscription drugs:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the hygienist at the next appointment without fail.

I agree to the privacy policy.

Dental Registration Form

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