Dr. Babak Khayatan

2734 Delta Fair Blvd, Antioch, CA 94509

(925) 778-1234

Dental Registration And History

Patient Information

First Name:

MI:

Last Name:

Date:

SS/HIC/Patient ID#:

SS/HIC/Patient ID #:

Address:

City:

State:

Zip:

E‐mail:

Sex:

Male Female

Age:

Birth Date:

Married Widowed Single Minor Separated Divorced Partnered for

Occupation

Occupation:

Patient Employer/School

Patient Employer/School:

Employer/School Address

Employer/School Address:

Employer/School Phone

Employer/School Phone:

Spouse's Name

Spouse's Name:

BirthDate

BirthDate:

SS#

SS#:

Spouse's Employer

Spouse's Employer:

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to Patient

Relationship to Patient:

Insurance Co

Insurance Co.:

Group #

Group #:

Is patient covered by additional insurance?

Yes No

Subscriber's Name

Subscriber's Name:

Birthdate

Birthdate:

SS#

SS#:

Relationship to Patient

Relationship to Patient:

Insurance Co

Insurance Co.:

Group #

Group #:

ASSIGNMENT AND RELEASE

I certify that I. and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent Guardian or Personal Representative

Use your mouse cursor or the tip of your finger to sign below

Your exported signature

Name of Patient, Parent, Guardian or Personal Representative:

Date:

Relationship to Patient

Relationship to Patient:

Phone Numbers

Home

Home:

Work

Work:

Ext

Ext:

Cell Phone

Cell Phone:

Spouse's Work

Spouse's Work:

Best time and place to reach you:

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)

Name

Name:

Relationship

Relationship:

Home Phone

Home Phone:

Work Phone

Work Phone:

Dental History

Reason for today's visit

Reason for today's visit:

Former Dentist

Former Dentist:

City/State

City/State:

Date of last dental visit

Date of last dental visit:

Date of last dental x-rays

Date of last dental x-rays:

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Bad breath

Yes No

Bleeding gums

Yes No

Blisters on lips or mouth

Yes No

Burning sensation on tongue

Yes No

Chew on one side of mouth

Yes No

Cigarette, pipe. or cigar smoking

Yes No

Clicking or popping jaw

Yes No

Dry Mouth

Yes No

Fingernail biting

Yes No

Food collecting between teeth

Yes No

Foreign objects

Yes No

Grind teeth

Yes No

Gums swollen or tender

Yes No

Jaw pain or tiredness

Yes No

Lip or cheek biting

Yes No

Loose teeth or broken fillings

Yes No

Mouth breathing

Yes No

Mouth pain, brushing

Yes No

Orthodontic treatment

Yes No

Pain around ear

Yes No

Periodontal treatment

Yes No

Sensitivity to cold

Yes No

Sensitivity to heat

Yes No

Sensitivity to sweets

Yes No

Sensitivity when biting

Yes No

Sores or growths in your mouth

Yes No

How often do you floss?

How often do you brush?

Health History

Physician's Name

Date of last visit:

Have you ever taken any of the group of drugs collectively referred to as 'fen-phenr These include combinations of lonimin. Adipex. Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No

Place a mark on "yes" or "no" to indicate if you have had any of the following.

AIDS/HIV

Yes No

Anemia

Yes No

Arthritis, Rheumatism

Yes No

Artificial Heart Valves

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Back problems

Yes No

Bleeding abnormally, with extractions or surgery

Yes No

Blood disease

Blood Disease

Yes No

Cancer

Yes No

Chemical dependency

Chemical Dependency

Yes No

Chemotherapy

Yes No

Circulatory problems

Circulatory Problems

Yes No

Congenital Heart Lesions

Yes No

Cortisone Treatments

Yes No

Cough, persistent or bloody

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting or dizziness

Yes No

Glaucoma

Yes No

Headaches

Yes No

Heart Murmur

Yes No

Heart problems

Heart Problems

Yes No

Hepatitis

Yes No

Type

Herpes

Yes No

High blood pressure

High Blood Pressure

Yes No

Jaundice

Yes No

Jaw pain

Jaw Pain

Yes No

Kidney disease

Kidney Disease

Yes No

Liver disease

Liver Disease

Yes No

Low blood pressure

Low Blood Pressure

Yes No

Mitral valve prolapse

Mitral Valve Prolapse

Yes No

Nervous problems

Nervous Problems

Yes No

Pacemaker

Yes No

Psychiatric care

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory disease

Respiratory Disease

Yes No

Rheumatic fever

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Shortness of breath

Shortness of Breath

Yes No

Sinus trouble

Sinus Trouble

Yes No

Skin rash

Skin Rash

Yes No

Special Diet

Yes No

Stroke

Yes No

Swollen Feet or Ankles

Yes No

Swollen neck glands

Swollen Neck Glands

Yes No

Thyroid problems

Thyroid Problems

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumor or growth on head or neck

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Weight loss, unexplained

Weight Loss, unexplained

Yes No

Do you wear contact lenses?

Yes No

WOMEN

Are you pregnant?

Yes No

Due date

Are you nursing ?

Yes No

Taking birth control pills?

Yes No

Medication

List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name

Phone

Allergies

Aspirin Barbiturates (Sleeping pills) Codeine Iodine Latex

Local Anesthetic Penicillin Sulfa Other

Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?

Yes No

If yes, please explain:

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Use your mouse cursor or the tip of your finger to sign below

Your exported signature

Date:

Doctor's Signature

Use your mouse cursor or the tip of your finger to sign below

Your exported signature

Date:

Has there been any change in your health since your last dental appointment?

Yes No

If yes, please explain:

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Use your mouse cursor or the tip of your finger to sign below

Your exported signature

Date:

Doctor's Signature

Use your mouse cursor or the tip of your finger to sign below

Your exported signature

Date: