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TMD
Back-to-School

Registration

Last Name First Name M.I.
Street
City State Zip
Home Phone Business Phone
Date of Birth Month Day Year
Sex Male Female Height Feet Inches Weight Lbs
Occupation Social Security #
Marital Status Name of Spouse
Spouse's Social Security #
Emergency Contact Relationship
Phone
Are you in good health?	Yes	No
Has there been any change in your general health within the past year?	Yes	No
My last physical examination was on Month Year
Are you under the care of a physician?	Yes	No
If so, what is the condition being treated?
Physician's Name
Physician's Street
Physician's City State Zip
Physician's Phone #
Have you ever been treated for a serious illness or operation?	Yes	No
If so, what was the illness or operation?
Have you been hospitalized or had a serious illness within the past five (5) years?	Yes	No
If so, what was the problem?
Do you have or have you had any of the following diseases or problems?
Rheumatic fever of rheumatic heart disease?	Yes	No
Congenital heart lesions?	Yes	No
Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, ateriosclerosis, stroke)?	Yes	No
Do you have pain in chest upon exertion?	Yes	No
Are you ever short of breath after mild exercise?	Yes	No
Do your ankles swell?	Yes	No
Do you get short of breath when you lie down or do you require extra pillows when you sleep?	Yes	No
Do you have a cardiac pacemaker?	Yes	No
Allergy?	Yes	No
Sinus Trouble?	Yes	No
Asthma or hay fever?	Yes	No
Hives or skin rash?	Yes	No
Fainting spells or seizures?	Yes	No
Diabetes?	Yes	No
Do you have to urinate (pass water) more than six times a day?	Yes	No
Are you thirsty much of the time?	Yes	No
Does your mouth frequently become dry?	Yes	No
Hepatitis, jaundice or liver disease?	Yes	No
Arthritis?	Yes	No
Inflammatory rheumatism (painful swollen joints)?	Yes	No
Stomach ulcers?	Yes	No
Kidney Trouble?	Yes	No
Tuberculosis?	Yes	No
Do you have a persistant cough or cough up blood?	Yes	No
Low blood pressure?	Yes	No
Veneral disease?	Yes	No
Other?
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?	Yes	No
Do you bruise easily?	Yes	No
Have you ever required a blood transfusion?	Yes	No
If so explain the circumstances
Do you have any blood disorder such as anemia?	Yes	No
Have you had surgery or x-ray treatment for a tumor, growth, or condition of your head or neck?	Yes	No
Are you taking any drug or medicine?	Yes	No
If so, what?
Are you taking any of the following:
Antibiotics or sulfa drugs?	Yes	No
Anticoagulants (blood thinners)?	Yes	No
Medicine for high blood pressure?	Yes	No
Cortisone (steroids)?	Yes	No
Tranquilizers?	Yes	No
Antihistimines?	Yes	No
Aspirin?	Yes	No
Insulin, tolbutamide (Orinase) or similar drug?	Yes	No
Digitalis or drugs for heart trouble?	Yes	No
Nitroglycerin?	Yes	No
Oral contraceptive or other hormonal therapy?	Yes	No
Are you allergic or have you reacted adversely to:
Local anesthetics?	Yes	No
Penicillin or other antibiotics?	Yes	No
Sulpha drugs?	Yes	No
Barbiturates, sedatives, or sleeping pills?	Yes	No
Aspirin?	Yes	No
Iodine?	Yes	No
Codeine?	Yes	No
Other?
Have you had any serious trouble associated with any previous dental treatment?	Yes	No
If so, explain
Do you have any disease, condition, or problem not listed above that you think I should know about?	Yes	No
If so, explain
Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation?	Yes	No
Are you wearing contact lenses?	Yes	No
If you are a woman are you pregnant?	Yes	No
If you are a woman do you have any problems associated with your menstrual period?	Yes	No
If you are a woman are you nursing?	Yes	No
My last complete dental exam was on Month Year
What treatment was done at that time?
What prompted you to seek dental care now?
Which dental specialists have you been treated by?
Registered Dental Hygienist Orthodontist Oral Surgeon
Periodontist Pedodontist Endodontist Prosthodontist Other
What's your main complaint concerning your mouth? Please explain.

Do you eat a lot sweets?	Yes	No
About how often do you use dental floss?
About how often are you troubled with bad breath?
Do your gums bleed when you brush your teeth?	Yes	No
Are any of your teeth loose?	Yes	No
Have you noticed gum shrinkage or recession?	Yes	No
Are you happy with the appearance of your smile?	Yes	No
Does food get stuck between certain teeth?	Yes	No
Are any of your teeth sensitive to sweets, biting pressure, hot or cold?	Yes	No
How many cups do you drink a day of coffee? tea? soda?
Are you happy with the appearance of your smile?	Yes	No
About how often do you smoke?
About how often do you drink alcoholic beverages?
Ever have any unusual lumps, bumps, or discolorations in your mouth or on your head, face or neck?	Yes	No
Do you have any oral habits like cheek biting, grinding or clenching your teeth while awake or asleep?*	Yes	No
Did you ever notice clicking, popping or crunching in your jaw joint (TMJ)?*	Yes	No
Have you ever had surgery of your teeth or jaws?	Yes	No
Do you have any unreplaced missing teeth?	Yes	No
Are you a "mouth breather?"*	Yes	No
What hobbies or activities do you enjoy?
What is your e-mail address?

* If you answered Yes to any of the items marked with a * please continue answering the TMD Screening by following the hyperlink.

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Send mail to Webmaster@SportsDDS.com with questions or comments about this web site.
Copyright 2016 Michael D. Kurtz, DDS