Dr. Rick Bonomo - Patient Registration Form

Dr Rick Bonomo DMD

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 ______

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:	_______________________________________

If you have an X-ray(s) please bring it/them with you to the office
with your completed form.

LEGAL STUFF