This is a printable version of our Registration Form if you prefer to complete by hand and carry with you on your first visit to Dr. Bonomo's office. If you would like to submit this information on-line click: HERE PATIENT IDENTIFICATION   Name: ______________________________________________ Age: ______ Date of Birth: _____/_____/_____ Home Phone: _________________ Work Phone: _________________ Address: ______________________________________________ City: ______________________________________________ State: _______ Zip: _________-________ Email: ______________________________________________ Social Security Number: _______-_____-_______ What is your weight: _________lbs. 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 Have you ever had a Heart Attack? Yes ______ No ______ Do you have a Pacemaker? Yes ______ No ______ Do you have an Artifical 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 had 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 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 for Admission: ______________________ ______________________
	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 ______ Do you anticipate becoming pregnant? Yes ______ No ______
	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: _______________________________________ If you have an X-ray(s) please bring it/them with you to the office with your completed form.
	Copyright by Dr. Rick Bonomo LEGAL STUFF