General Info Map to Office Patient Registration Post Op Instructions Antibiotics Wisdom Teeth Dental Implants What is TMJ? Disclaimer Home e-mail		You may submit this information prior to your appointment to minimize wait time. Or, review the questions so that you can have all this information easily available. Click HERE to print a REGISTRATION FORM.
			Appointment Date: Would you like our office to call you to arrange an appointment? Yes No PATIENT IDENTIFICATION Name: Age: Date of Birth: Home Phone: Work Phone: Address: City: State: Zip: Email: Social Security Number: What is your weight: Family Dentist: Last Dental Appointment: Family Medical Doctor: PLEASE HELP US: Which of the following was most responsible for your choosing Dr. Bonomo for your Oral Surgery needs? Here Before Friend Family Member Medical Doctor Other Yellow Pages Dentist Name: Emergency Room at (Hospital name)
	CHIEF COMPLAINT		What is the reason you are seeing Dr. Bonomo? What is your perception of your current oral health?
	PAST MEDICAL HISTORY		PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS: Have you ever had a Heart Attack?  Yes  No Do you have a Pacemaker?  Yes  No Do you have an Artificial Heart Valve?  Yes  No Do you have an Artificial Joint (Knee, Hip, other)?  Yes  No Have you ever been told that you are Anemic?  Yes  No Do you have pain in your Jaw Joint (TMJ)?  Yes  No Have you ever has a Stroke?  Yes  No Do you have Glaucoma?  Yes  No Do you have H.I.V. or A.I.D.S.?  Yes  No Have you ever received X-ray treatment for Cancer?  Yes  No Do you have a Thyroid Disease?  Yes  No Are you taking Cortisone Medicine?  Yes  No Are you being treated for Diabetes?  Yes  No Are you being treated for High Blood Pressure?  Yes  No Did you ever have Rheumatic Fever?  Yes  No Have you ever been told that you have a heart murmur? (A heart murmur is an abnormal sound in the heart)  Yes  No Have you ever had Hepatitis or Liver Disease?  Yes  No Date: Have you ever had Kidney Disease?  Yes  No Have you ever had breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, T.B., or any other lung disorder? Please list all that apply, or other:  Yes  No Please List:
	PAST HOSPITAL ADMISSIONS		Have you ever been admitted to a hospital?  Yes  No Please list reasons admitted:
	MEDS		Please list any medications that you are taking: None Please List:
	ALLERGIES		Do you have allergies to any drugs or medical devices such as: "Novocaine" Latex Gloves None Penicillin I.V. Tubing Other: Codeine Tape If yes: exactly what is your reaction to each ?
	REVIEW OF SYSTEMS		When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?  Yes  No Do you have Shortness of Breath?  Yes  No Are you subject to fainting, dizziness, nervous disorders, convulsions or epilepsy?  Yes  No Other Neurological Conditions: Do you bleed excessively after a cut, wound, or surgery?  Yes  No
	WOMEN ONLY		Are you pregnant now?  Yes  No Are you practicing birth control?  Yes  No Are you taking Birth Control Pills?  Yes  No Do you anticipate becoming pregnant?  Yes  No Please note that birth control pills may be rendered ineffective by antibiotics (such as Penicillin). If you are taking birth control pills and the doctor prescribes an antibiotic for you, you are advised to use an additional method of contraception during the present menstrual cycle. I have read and I understand the above: (Please check)
	FAMILY HISTORY		Does anyone in your immediate family have difficulty with anesthetics when they are put to sleep?  Yes  No If yes please explain: Have you ever been treated by Dr Bonomo?  Yes  No Year Last Treated Please list names of family members treated and their relationship to you: Your Marital Status: Single Married Separated Divorced
	SOCIAL HISTORY		Do you smoke cigarettes?  Yes  No If yes, how many packs per day? Do you use alcohol?  Yes  No If yes, how much oz./day /week
	INSURANCE		What is your occupation? Name of Employer: Name of Dental Insurance Carrier: Phone Number of Dental Insurance Carrier: Name of Medical Insurance Carrier: Phone Number of Medical Insurance Carrier: Group Policy Number : Subscriber/Policy Holder Name: Identification #: Subscriber Date of Birth:
			Click on Reset to clear form and start again: If all information is correct please click on Submit button : (Only click once)   If requested, you will be contacted during the next business day.   If you have a digital file of your X-ray please attach it to an e-mail message to cathy@drbonomo.com
			Copyright by Dr. Rick Bonomo LEGAL STUFF