Welcome to Dr. Tortorella's OfficeREGISTRATION INFORMATIONDate(Required) MM slash DD slash YYYY REGISTRATION INFORMATIONYour co-operation in completing this questoinaire is essential to providing you with the highest standard of dental care. All information is strictly confidential and will remaind with this office. Our receptionist is available to assist with the completion of this form.This patient is an:(Required) Adult Child Adult under guardianship Name of Guardian: Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Reason for today's visit?(Required) Examination Emergency Other If other:(Required) Home Phone:(Required)Cell Phone:(Required)Bus. Phone:Ext.Employer: May we call you at work?(Required) Yes No Email address:(Required) Prefers to be called: First Date(Required) MM slash DD slash YYYY Sex:(Required) Marital Status:(Required) Name of Spouse: Are other family members patients at our office?(Required) Yes No Names: Whom may we thank for referring you? Family Physician(Required) Phone:(Required)Medical Specialist (if presently under care)Phone:In case of emergency, please contact:(Required) First Phone(Required)Nearest relative not living with you: First PhoneDENTAL HISTORYPlease check YES or NO to each question. If unsure of a question, please consult the dentist.Is there a problem you would like treated immediately?(Required) Yes No Please describe what you would like treated.Date of your last dental visit?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of your last dental cleaning?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of your last x-rays?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you having regular dental visits?(Required) Yes No Have you ever had any of the following:(Required) Periodontal Treatment (treatment of gums)? Orthodontic Treatment )to straighten or realign teeth)? a bite plate or any other appliance? Your bite adjusted or teeth ground? Oral Surgery (surgery in or about the mouth/jaw joint, implant surgery in one or both of your jaw joints)? None of the above How often do you brush your teeth?(Required) Do you feel that you have bad breath?(Required) Do you use dental floss, proxabrush or stimudents?(Required) How often?(Required) Do your gums bleed when brushing, or eating or do you suffer from pain or swelling of your gums?(Required) Yes No Does food catch between your teeth?(Required) Yes No Are any of your teeth sensitive to heat, cold, sweets or pressure?(Required) Yes No Have you ever experienced any of the following jaw problems?(Required) Poppin/clicking in your jaw joints? Pain in your jaw joints, around your ear, or the side of your face? Difficulty in opening or closing? Pain when teeth are clenched? Pain or difficulty when chewing? None of the above Do you have any of the following habits?(Required) Clenching or grinding your teeth while awake or asleep? Biting your cheeks or lips? Mouth breathing while awake or asleep? Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)? None of the above Do you have any emotional concerns about having dental treatment?(Required) Yes No if yes: Are you happy with the appearance of your teeth?(Required) Yes No if no: Have you ever had upsetting experience in a dental office, or any complications during or following dental treatment, or do you have any questions or concerns?(Required) Yes No if yes: HEALTH HISTORYPlease check YES or NO to each question.Are you being treated for any medical condition at present or within the past year?(Required) Yes No if yes, please explain?(Required) When was your last visit to a physician?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last complete physical examination?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920List any PRESCRIPTION OR NON-PRESCRIPTION drugs you are taking or having recently taken (including birth control pills):(Required) Have you ever had any adverse or unusual reaction to any medications or injections? (e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic (dental freezing)"?(Required) Yes No if yes, please explain? Have you ever been advised against taking any specific type of medication?(Required) Yes No if yes, please explain? Do you have any allergies (e.g. hay fever, food allegies, latex/rubber or metal allergies)?(Required) Yes No if yes, please list: Have you ever fainted during dental or medical treatment?(Required) Yes No if yes: Do you bleed excessively from a cut or injury, bruide easily or have any blood disorders?(Required) Yes No if yes, please explain? Are you on cortisone, or steroid therapy, or, are you on a diet pill therapy?(Required) Yes No if yes, please explain? Do you have any artificial joints (e.g. hip, knee)?(Required) Yes No if yes, please explain? Have you ever been advised to take antibiotics before dental treatment?(Required) Yes No if yes, please explain? Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic Fever?(Required) Yes No if yes, please explain? Do you have, or have you ever had, any heart or blood pressure problems (heart or stroke)?(Required) Yes No if yes, please explain? Do you have or have you ever had any chest pain, shortness of breath or any heart palpitation without exertion?(Required) Yes No if yes, please explain? Are you presently suffering from any infectious disease?(Required) Yes No if yes, please explain? Do you have any condition that could affect your immune system? (e.g. arthritis, AIDS, HIV Infection, lupus, inflammatory bowel disease. Chron's?)(Required) Yes No if yes, please explain? Guardian/Parent Signature(Required)Date(Required) MM slash DD slash YYYY Δ
