Richmond West End / Glen Allen 804-270-7737

Family and cosmetic dentistry

We provide individualized treatment geared
toward improving your dental & overall health.

Learn More

Dental Registration and History

Home »  Online Forms »  Dental Registration and History

View complete document

    Required fields are in *Bold

    Patient Information

    male female



    In Case Of Emergency: Please give two contact names

    Dental Insurance


    Dental History

    Please place an X to indicate if you
    badbreath Bad breath

    bleedinggums Bleeding gums

    lipblisters Blisters on lips or mouth

    tongueburningsensation Burning sensation on tongue

    chewmouth1side Chew on one side of mouth

    chewtobacco Chewing tobacco

    smoking Cigarette, pipe, or cigar smoking

    clickingjaw Clicking or popping of jaw

    drymouth Dry mouth

    fingernailbiting Fingernail biting

    orthodontics Orthodontic treatment

    periodontal Periodontal treatment

    coldsensitivity Sensitivity to cold

    heatsensitivity Sensitivity to heat

    sweetsensitivity Sensitivity to sweets

    foodcollectionbetweenteeth Food collection between teeth

    sores Sores or growths in mouth

    grindingteeth Grinding teeth

    swollengums Gums swollen or tender

    jawpaintiredness Jaw pain or tiredness

    lipbiting Lip or cheek biting

    looseteeth Loose teeth or broken fillings

    mouthbreathing Mouth breathing

    earpain Pain around ear

    Health History

    aids AIDS/HIV

    anemia Anemia

    arthritis Arthritis, Rheumatism

    artificalheartvalve Artificial Heart Valves

    artificaljoints Artificial Joints

    asthma Asthma

    backproblems Back Problems

    bleeding Bleeding (w/ extractions or surgery)

    blooddisease Blood Disease

    cancer Cancer

    chemicaldependency Chemical Dependency

    chemotherapy Chemotherapy

    cortisonetreatments Cortisone Treatments

    cough Cough, persistent or bloody

    diabetes Diabetes

    emphysema Emphysema

    epilepsy Epilepsy

    faintingdizziness Fainting or Dizziness

    glaucoma Glaucoma

    headaches Headaches

    heartmurmur Heart murmur

    heartproblems Heart problems

    hepatitis Hepatitis,

    herpes Herpes

    highbloodpressure High blood pressure

    jaundice Jaundice

    jawpain Jaw pain

    kidneydisease Kidney disease

    liverdisease Liver disease

    lowbloodpressure Low blood pressure

    mitralvalveprolapse Mitral Valve Prolapse

    nervousproblems Nervous problems

    pacemaker Pacemaker

    psychiatriccare Psychiatric care

    radiationtreatments Radiation treatments

    respiratorydisease Respiratory disease

    rheumaticfever Rheumatic fever

    shortnessofbreath Shortness of breath

    sinustrouble Sinus trouble

    skinrash Skin rash

    specialdiet Special diet

    stroke Stroke

    swollenfeetorankles Swollen feet or ankles

    swollenneckorglands Swollen neck glands

    thyroidproblems Thyroid problems

    tonsilitis Tonsillitis

    tuberculosis Tuberculosis

    tumororgrowth Tumor or growth on head/neck

    ulcer Ulcer

    venerealdisease Venereal disease

    unexplainedweightloss Weight loss, unexplained

    Generate signature (Responsible party)Leave blank and print

    Richmond West End / Glen Allen 11551 Nuckols Road - Suite B Glen Allen, VA 23059

    Open Monday to Thursday 8AM TO 5PM

    Skip to content