New Patient Registration Form - Dr. David A. Knopf

General Information

Name *

First

Last

Date of Birth *

Age

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address (If Different)

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information

Cellular Phone

Home Phone

Work Phone

Email Address *

Referred To Us By

Preferred Contact Method: *

Preferred Billing Statement Method: *

Insurance Information

Primary Insured Name

Primary Member's Date of Birth

Primary Dental Insurance

Primary Insurance Member ID

Group Name (Employer)

Group Number

Secondary Insured Name

Secondary Member's Date of Birth

Secondary Dental Insurance

Secondary Insurance Member ID

Secondary Group Name (Employer)

Secondary Group Number

Healthcare Provider Information

Name of Your Medical Doctor

Medical Doctor Phone Number

Date of Last Visit

Name of Previous Dentist

Date of Last Visit

Dental Health History

Are you apprehensive about dental treatment

Yes
No

Have you had problems with previous dental treatment?

Yes
No

Do you gag easily?

Yes
No

Do you wear dentures?

Yes
No

Does food catch between your teeth?

Yes
No

Do you have difficulty chewing your food?

Yes
No

Do you chew on only one side of your mouth?

Yes
No

Do you chew on only one side of your mouth because of pain?

Yes
No

Do your gums bleed easily?

Yes
No

Do your gums feel swollen or tender?

Yes
No

Have you ever noticed slow-healing sores in or about your mouth?

Yes
No

Are your teeth sensitive?

Yes
No

Do you feel twinges of pain when your teeth come in contact with hot foods or liquids?

Yes
No

Cold foods or liquids?

Yes
No

Sours?

Yes
No

Sweets?

Yes
No

Do you take fluoride supplements?

Yes
No

Are you dissatisfied with the appearance of your teeth?

Yes
No

Do you prefer to save your teeth?

Yes
No

Do you want complete dental care?

Yes
No

How often do you brush?

How often do you floss?

Does your jaw make noise so that it bothers you or others?

Yes
No

Do you clench or grind your jaws frequently?

Yes
No

Do your jaws ever feel tired?

Yes
No

Does your jaw get stuck so that you can't open or close freely?

Yes
No

Does it hurt when you chew or open wide to take a bite?

Yes
No

Do you have earaches or pain in front of the ears?

Yes
No

Do you have any jaw symptoms or headaches upon awaking in the morning?

Yes
No

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?

Yes
No

Do you find jaw pain or discomfort extremely frustrating or depressing?

Yes
No

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?

Yes
No

Do you have a temporomandibular (jaw) disorder (TMD)?

Yes
No

Do you have pain in the face, cheeks, jaws, joints, throat, or temples?

Yes
No

Are you unable to open your mouth as far as you want?

Yes
No

Are you aware of an uncomfortable bite?

Yes
No

Have you had a blow to the jaw (trauma)?

Yes
No

Are you a habitual gum chewer or pipe smoker?

Yes
No

Do you snore?

Yes
No

Are you excessively tired during the day?

Yes
No

Have you been told you stop breathing during sleep?

Yes
No

Is your neck size greater than 17 inches (male) or 16 inches (female)?

Yes
No

Medical Health History

Heart problems:

Yes
No

Chest pain

Yes
No

shortness of breath

Yes
No

Blood pressure problem

Yes
No

Heart murmur

Yes
No

Heart valve problem

Yes
No

Taking heart medication

Yes
No

Rheumatic fever

Yes
No

Pacemaker

Yes
No

Artificial heart valve

Yes
No

Blood problems:

Yes
No

Easy bruising

Yes
No

Frequent nosebleeds

Yes
No

Abnormal bleeding

Yes
No

Blood disease (anemia)

Yes
No

Ever require a blood transfusion?

Yes
No

Allergy Problems:

Yes
No

Hay fever

Yes
No

Sinus problems

Yes
No

Skin rashes

Yes
No

Taking allergy medication

Yes
No

Asthma

Yes
No

Intestinal Problems:

Yes
No

Ulcers

Yes
No

Weight gain or loss

Yes
No

Special diet

Yes
No

Constipation/Diarrhea

Yes
No

Kidney or bladder problems

Yes
No

Bone or Joint Problems:

Yes
No

Arthritis

Yes
No

Back or neck pain

Yes
No

Joint replacement (e.g. total hip, pins, or implants)

Yes
No

Are you taking or have you taken Bisphosphonate (e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast, etc.)

Yes
No

Fainting Spells, Seizures or Epilepsy

Yes
No

Stroke(s)

Yes
No

Frequent or severe headaches

Yes
No

Thyroid problems

Yes
No

Persistent cough or swollen glands

Yes
No

Premedications required by physician

Yes
No

Cancer/tumor

Yes
No

Diabetes

Yes
No

Urinate more than 6 times a day

Yes
No

Thirsty or mouth is dry much of the time

Yes
No

Family history of diabetes

Yes
No

Tuberculosis or other respiratory disease

Yes
No

Do you drink alcohol?

Yes
No

If so, how much?

Do you smoke?

Yes
No

If so, please describe

Hepatitis, jaundice, or liver trouble

Yes
No

Herpes or other STD

Yes
No

HIV-positive / AIDS

Yes
No

Glaucoma

Yes
No

Do you wear contact lenses?

Yes
No

History of head injury?

Yes
No

Epilepsy or other neurological disease?

Yes
No

History of alcohol or drug abuse?

Yes
No

Do you have any disease, condition, or problem not listed previously that you feel we should now about?

Yes
No

If so, please describe

Please list any recent surgeries and dates:

Are you allergic, or have you reacted adversely to any of the following?

Aspirin

Yes
No

Codeine

Yes
No

Dental Anesthetics

Yes
No

Erythromycin

Yes
No

Jewelry

Yes
No

Latex

Yes
No

Metals

Yes
No

Penicillin

Yes
No

Tetracycline

Yes
No

Sulfa

Yes
No

Other

Yes
No

During the past 12 months, have you taken any of the following?

Antibiotics or sulfa drugs

Yes
No

Anticoagulants (e.g., Coumadin)

Yes
No

High blood pressure medicine

Yes
No

Tranquilizers

Yes
No

Insulin, Orinase, or similar drug

Yes
No

Aspirin

Yes
No

Digitalis or drugs for heart trouble

Yes
No

Nitroglycerin

Yes
No

Cortisone (steroids)

Yes
No

Natural remedies

Yes
No

Nonprescription drug/supplements

Yes
No

Other

Please list any medications you are currently taking:

For Women:

Are you taking birth control pills or other hormones?

Yes
No

Are you pregnant?

Yes
No

If yes, number of weeks:

Are you nursing?

Yes
No

Have you reached menopause?

Yes
No

If so, do you have any symptoms?

Please read the following 2 documents carefully:

Financial Policy Statement

Privacy Practices Statement

Acknowldgement *

I acknowledge that I have read and understand the above documents & information.

Signature

Clear Signature

I have read the financial policy and privacy practices statements and understand the information.

Please read the following 2 documents carefully:

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