Dr. Judy Sturm & Associates is a place of comfort, care, and friendliness. We look forward to welcoming you to our Dental Family.
Patient Registration Form
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Whom may we thank for referring you?
Are any other members of your family patients at our practice?
Yes, insurance applies to meNo, insurance does not apply to me
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient condentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.
Are you being treated for any medical condition at the present or any time within the past year?
When was your last medical check-up?
Has there been any change in your general health in the past year?
Are you taking any prescription, non-prescription medications, or herbal supplements?
Do you have any allergies?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or ever had asthma?
Do you have or ever had any heart or blood pressure problems?
Have you ever/do you have an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Do you have a prosthetic or articial joint?
Do you have any conditions which may aect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Are there any conditions/diseases not listed that you have or have had?
Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
For women only: Are you pregnant?
For women only: Are you breastfeeding?
Do you have any specific dental concerns? Please list
When was your last dental appointment?
How often do you see the dentist?
Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?
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