Dental Registration English Name* First Last Name & Location of last dental provider:Date of last Dental Visit: Date Format: MM slash DD slash YYYY Date of last Dental X-Rays: Date Format: MM slash DD slash YYYY My past dental experiences have been:EventfulUneventfulOn 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?YesNoAre you nervous or do you have anxiety about coming to the dentist or receiving dental treatment?YesNoHave you had a bad experience with a dentist/dental procedure?YesNoHave you ever had any complications following dental treatment?YesNoIf yes, please explain:Do you/have you ever needed to premedicate prior to dental treatment?YesNoHave you had a knee or hip replacement?YesNoAre you pregnant or nursing?YesNoDo you have bleeding gums?YesNoDo you have receding gums?YesNoDo you have history of gum diseases (gingivitis, periodontal disease)?YesNoHave you ever needed to be numbed for a dental cleaning?YesNoDo you experience dry mouth?YesNoDo you have any sore, lesion, ulceration, abnormality that has not healed within 14 days?YesNoDo you have persistent hoarseness, change in voice, sore throat?YesNoDo you have any persistent pain, numbness in the head and neck region?YesNoDo you have a mass or lump on head, neck, or inside of mouth?YesNoDo you have difficulty or pain in swallowing, sensation of something stuck in the throat?YesNoDo you have a persistent cough?YesNoDo you experience unilateral persistent ear or jaw pain?YesNoDo you have fatigue, exhaustion, unexplained weight loss?YesNoHave you tested positive for Human Papillomavirus/HPV?YesNoDo you have personal or family history of head & neck, oral, oropharyngeal cancer, Squamous Cell Carcinoma?YesNoIs there anything you would like to change about your dental health?YesNoIs there anything you would like to discuss today regarding your dental health?YesNoIf 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 HistoryDate of last physician (medical Doctor) visit: Date Format: MM slash DD slash YYYY Physicians Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix Last Physician/ Office Phone NumberHave you ever had any of the following? Please check those that apply: Aids Allergies Asthma Anemia Arthritis Artificial Joints Cancer Blood Disease Cold Sores Diabetes Dizziness Epilepsy/seizures Excessive Bleeding Fainting GERD Glaucoma Growths Hay Fever Head Injuries Heart Murmur Hepatitis High Blood Pressure Jaundice Joint Replacements Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Skin Cancer Sleep Apnea Stomach Problems Stroke Tuberculosis Tumors Ulcers Thyroid Problem If selected "Pregnancy" above. Please enter due date here: Date Format: MM slash DD slash YYYY 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?YesNoAre you now under the care of a physician?YesNoIf yes, please explain:Do you have any health problems that need further explanation?YesNoIf 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.