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Jay Sison D.D.S., D.M.Sc.

8540 South Sepulveda Boulevard Los Angeles, California 90045

310-215-1180

Patient Registration

ID:
Chart ID:
First Name:
Last Name:
Patient is:

Responsible Party (if someone other than the patient)

First Name:
Last Name:
Address:
City:
State:
Zip:
Pager:
Home Phone:
Work Phone:
Ext:
Cellular:
Birth Date:
Soc. Sec:
Drivers Lic:
Responsible Party is

Patient Information

Address:
City:
State:
Zip:
Pager:
Home Phone:
Work Phone:
Ext:
Cellular:
Sex:
Marital Status:
Birth Date:
Age:
Soc. Sec:
Drivers Lic:
E‐mail:

Section 2

Employment Status:
Student Status:
Medicaid ID:
Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
Pref. Hyg.:

Primary Insurance Information

Name of Insured:
Relationship to Patient:
Insured Soc. Sec:
Insured Birth Date:
Employer:
Address:
City:
State:
Zip:
Insurance Company:
Address:
City:
State:
Zip:
Rem. Benefits: .00
Rem. Deduct: .00

Secondary Insurance Information

Name of Insured:
Relationship to Patient:
Insured Soc. Sec:
Insured Birth Date:
Employer:
Address:
City:
State:
Zip:
Insurance Company:
Address:
City:
State:
Zip:
Rem. Benefits: .00
Rem. Deduct: .00

Patient's Signature:

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Date:

Guardian's Signature:

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Date:

Medical History

Please answer all questions. Answers to the following questions are for our records only and will be considered confidential.

Name:
E‐mail:
Phone:
Are you in good health?
Height:
Weight:
Has there been any change in your general health?
Your last physical examination was on:
Are you now under the care of a physician?
Name of your physician:
Address of your physician:
Have you ever had a serious illness or operation?
Have you been hospitalized with any of the following within the last 5 years?
Do you have a persistent cough or cough up blood?
Low/High blood pressure(circle one)
Venereal Disease
AIDS or HIV+
Other:
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
Do you bruise easily?
Have you ever required a blood transfusion
If yes, explain the circumstances:
Do you have any blood disorder such as anemia?
Have you had surgery or x‐ray treatment for a tumor, growth or other condition of your mouth or lips?

Medications

Are you taking any drug or medication?
If yes, what?
Are you taking any of the following?
Antibiotics or sulfa drugs
Tranquilizers
Cortisone (steroids)
Medicine for high blood pressure
Insulin, Tolbutamide (Orinase) or similar drug
Digitalis or drugs for heart trouble
Osteoporosis Drugs (Fosamax, Aredia, Zometa etc.)
Aspirin
Anticoagulants (blood thinners such as Coumadin, Plavix etc)
Nitroglycerin
Any natural product, herbal supplement or homeopathic remedy?
Chemotherapy Drugs
Fen‐Phen (now or in the past) or related drug such as Ionimin, Adipex, Phentermine, Fastin, Pondimin (Fenfluramine), and Redux (dexfenfluramine)
Oral Contraceptives
If yes, what are you using?
Other:

Habits

Do you smoke?
If yes, how much?
Do you drink alcoholic beverages?
Do you take any recreational drugs?

Do you have any of the following?

Cardiac pacemaker
A removable dental appliance
Implants/Artificial prosthesis (Knee joints, elbow pins etc)

Do you have, or have you had, any of the following diseases or problems?

Rheumatic fever or rheumatic heart disease
Hepatitis, jaundice, or liver disease
Heart Murmur or mitral valve prolapse
Congenital heart lesions
Convulsions/epilepsy
Stroke
Asthma or hay fever
Hives or skin rash
Fainting spells or seizures
Arthritis
Inflammatory rheumatism (painful, swollen joints)
Stomach ulcers
Kidney trouble
Tuberculosis
A tumor or growth
Radiation therapy or chemotherapy
Thyroid trouble
Bleeding tendency /abnormal bleeding
Are you immunosuppressed? Possibly from transplant surgery
Cardiovascular disease (heart trouble, heart attack, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
Do you have pain in the chest upon exertion?
Are you ever short of breath after mild exercise?
Do you get short of breath when you lie down or do you require extra pillows when you sleep?
Diabetes
Do you have to urinate (pass water) more than six (6) times a day?
Are you thirsty much of the time?
Does your mouth frequently become dry?

Allergy

Are you allergic or have you reacted adversely to:
Local anesthetic
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine
Valium or other tranquilizer
Aspirin
Iodine
Latex
Penicillin or other antibiotics (such as amoxicillin, clindamycin, erythromycin, Keflex etc)
Other:
Have you had any serious trouble associated with previous dental treatment?
If yes, explain:

For Women Only

Are you pregnant or could you be?
If yes, when are you due?
Are you nursing?
Are you taking oral contraceptives?
If yes, what?
Comments:

I certify to the best of my knowledge that the above information is correct and that if there are any changes in the above, I agree to notify my dentist or my surgeon before my next visit.

Patient's Signature:

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Date:

Guardian's Signature:

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Name:
Date:

Doctor's Signature:

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Name:
Date:

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