Larnerperio.com

JEFFREY R. LARNER, DDS, MS, PC
PATIENT REGISTRATION

Patient Name: _______________________ ___________ _______________________________ Preferred to be called: _________________
First Middle Last

Date of Birth: _____________________ SSN: __________________________ Email: ________________________________________________
Age: _______  Mr.  Mrs .  Miss  Ms.  Dr. Marital Status:  Single  Married  Partnered  Divorced  Widowed
Address: __________________________________________________________________ __________________________ _______ _______
Street/Apt# City

Home #: ________ ________________________Cell #: ________ _________________________ Work #: ________ ________________________
Preferred way to contact you:  Home  Cell  Work  E-mail Other Family members seen in office: _________________________
If Patient is a Minor: Father/Guardian: _______________SSN#_______________ Mother/Guardian: _______________SSN#_______________
Patient’s Employer: ________________________________________ Patient’s Occupation: _________________________________________
Spouse / Partner’s Name: ___________________________________ Spouse / Partner’s Phone #: ____________________________________
Emergency Contact: _______________________________________ Phone #: _________________________________________
Referred By: ___________________________________ General Dentist: __________________________________

Chief Complaint – Purpose of Visit: ________________________________________________________________________________________
DENTAL INSURANCE INFORMATION
Primary Insurance: _________________________ Group #: _______________________ Employer: __________________________________

Relationship to Patient: _______________ Policy Holder’s SSN: _________________________ DOB of Policy Holder: __________________
Secondary Insurance: ______________________ Group #: _______________________ Employer: __________________________________

Relationship to Patient: _______________ Policy Holder’s SSN: _________________________ DOB of Policy Holder: __________________
MEDICAL HISTORY
Are you under of the care of a physician other than routine care?
If yes, explain: ______________________________________________
Have you been hospitalized or had major surgery?
If yes, explain: ______________________________________________
Have you ever had excessive bleeding requiring treatment?
If yes, explain: ______________________________________________
Please list any prescribed medications you are taking, including any over-the-counter drugs and inhalers?
____________________________________________ 5. ____________________________________________
____________________________________________ 6. ____________________________________________
____________________________________________ 7. ____________________________________________
____________________________________________ 8. ____________________________________________
Are you allergic to, had a reaction to, or been told not to take any medications? If yes, please list.
____________________________________________ 4. ____________________________________________
____________________________________________ 5. ____________________________________________
____________________________________________ 6. ____________________________________________
Do you take any of these medications? If yes, check box.
 Daily Aspirin  Efficient  Coumadin/Warfarin  Plavix  Persantine  Ticlid  Aggrenox  Pletal  Pradaxa  Eliquis  Xarelto
Do you have Diabetes?
Have you been told you have  High or  Low Blood Pressure?
Have you been told to premedicate with antibiotics for dental procedures?
Have you ever had:  hip  knee or  other joint replacement? When? ________________________
Have you ever had:  rheumatic fever heart murmur  mitral valve prolapse  heart stent  arrythemia
Have you ever had cancer/radiation/chemotherapy? When? _________ Cancer Type:____________________
Have you ever had kidney, bladder or thyroid problems? If yes, explain: ______________________________
Have you ever had liver problems or hepatitis? If yes, explain: _____________________________________
Are you HIV+ or do you have AIDS? If yes, explain: _______________________________________________
Have you ever had breathing problems, asthma, emphysema, TB? If yes, explain: ____________________
Have you ever had anemia, or any blood problems? If yes, explain: __________________
Do you have arthritis or joint pain requiring an NSAID? If yes, explain: _______________________________
Are you pregnant?  Yes  No When is your due date? ____________________________
Do you smoke cigarettes?  Yes  No How many per day? __________ Do you use other tobacco products?____________________
Do you now, or have you ever taken, bisphosphonates?  Yes  No When? __________________________
 Fosamax  Boniva  Zometa  Actonel  Reclast  Aredia Other: _______________________
Please list any other medical conditions you feel we need to know:
_______________________________________________________________________________________
DENTAL HISTORY
Are you experiencing discomfort in your mouth?, if yes, explain: _____________________________________________________________
Have you ever had gum surgery? When? _______________ Have you ever Scaling and Root Planing? When? ______________________
When was you last cleaning? ________________________ How often do you have your teeth cleaned? __________________________
Do you notice yourself clenching or grinding your teeth?
Have you noticed any mouth odors or bad taste in your mouth?
Please list any other dental conditions you feel we need to know:
_______________________________________________________________________________________
The above information is accurate and complete to the best of my knowledge. I understand that I am financially responsible for all
charges whether or not paid by insurance. I authorize the release of any information necessary to secure payment of insurance benefits
and assign benefits directly to Dr. Larner.
Signature: ________________________________________________________ Date: ___________________________

Source: http://www.larnerperio.com/pdf/medical-history.pdf