Mill Creek Dentistry near Seattle – Dentist Bull Mulliken, DDS

Patient Registration
Dental History
Medical History

Early Patient Registration These forms have been designed to expedite the patient registration process once your appointment has been scheduled. The information provided here is kept strictly confidential and will not be shared with any third party carriers. If a particular field does not apply to you please enter "N/A" or "None." * indicates required fields
All Fields are Required. Thank you. Patient Information
* Address Me As:
* First Name:
Middle Initial:
* Last Name:
* Date of Birth:
* Social Security Number:
* Email Address:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:

Student:	Yes	No
Enrollment Status:	Full time
	Part time
	N/A
Employer:

Emergency Contact Information
Name:
Relationship:
Phone:

Dental Insurance Information
Dental Insurance Carrier Name:
Policy Holder´s Name and Relationship:
Policy/Member ID Number:
Group Number:
Customer Service Phone Number:

Responsible Party
Only to be filled out if other than the patient
First Name:
Middle Initial:
Last Name:
Date of Birth:
Age:
Social Security Number:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Employer:
Relationship to Patient:

Dental History
Reason for Visit:
Date of Last Visit:
Last Dental Cleaning:
Last Full Mouth X-Ray:
What was done at your last dental visit?
Previous Dentist's Name:
Previous Dentist's Address:
Previous Dentist's Telephone:
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use?
Do you have any dental problems now?
If yes, please describe:
Are any of your teeth sensitive to: (check no or yes)
	No	Yes
Hot or cold?
Sweets?
Biting or chewing?
Have you noticed any mouth odors or bad taste?
Do you frequently get cold sores, blisters or other lesions?
Do your gums bleed or hurt? (check no or yes)
	No	Yes
Have your parents experience gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to become caught in between your teeth?
If yes, where:
Do you: (check no or yes)
	No	Yes
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with you teeth (pencils, pipe, pins, nails, fingernails)?
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Smoke or Chew tobacco?
Have you ever had: (check no or yes)
	No	Yes
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
If so, please describe, including cause:
Have you experienced: (check no or yes)
	No	Yes
Clicking or popping of the jaw?
Pain?(joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neck aches or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with you teeth's appearance?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?
If so, what is your biggest concern:
Have you ever had an upsetting dental experience?
If yes, please describe:
Is there anything else about having dental treatment that you would like us to know?
If yes, please describe:
Medical History
	No	Yes
1. Have you been under the care of a medical doctor during the past two years?
If yes, for what:
Physician's Name:
Phone:
Address:
City:
State:
Zip:
	No	Yes
2. Have you taken any medication or drugs during the past 2 years?
3. Are you taking any medication, drugs, or pills now (including regular doses of aspirin)?
If yes, please list name and dosage?
4. Have you ever taken prescription medications for weight loss (diet pills)?
If yes, did you take any of the following? (Check no or yes)
Fen-Phen (Fenfluramine-Phentermine)
Pondimen (Fenfluramine)
Redux (Dexfenfluramine)
If you answered yes to any of the above, did you have a medical exam for heart issues?
5. If you know of any allergic (or adverse) reaction to any medication or substance, please list:
6. Have you been a patient in the hospital during the past five years?
7. Indicate which of the following you have had, or have at present. (Check no or yes)
	No	Yes
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (hip, knee, etc.)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact Lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (infectious B (serum)
Venereal Disease
A.I.D.S.
H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
8. Do you use more than two pillows to sleep?
9. Have you lost or gained more than 10 pounds in the past year?
10. Do you have or have you had any disease, condition, or problem not listed?
If yes, please list:
11. Women:
Pregnant (if yes, please indicate how many months):
Nursing?
Taking birth control pills?
Payment Policy
I understand and agree that (regardless of insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. I have read all of the information on this page and have completed the above answers. I certify this information is true and correct. I will notify you of any changes in health status or the above information.
	No	Yes
I have read and understand the Payment Policy above.

Contact Mill Creek Dentistry near Seattle to schedule a consultation with dentist Bill Mulliken, DDS.

Bill Mulliken, DDS
Mill Creek Dentistry
16030 Bothell/Everett Hwy.
Suite 280
Mill Creek, WA 98012

Ph: 425-481-4974
Ph: 425-337-4001
Fx: 425 338-4930

Patient Registration
Dental History
Medical History

Patient Privacy Notice
Practice Privacy Notice

Welcome to Mill Creek Dentistry! Seattle-area residents have been coming to dentist Bill Mulliken for more than 20 years. We welcome residents of Everett, Lynnwood, Kirkland, Redmond, and beyond. Come to us for a consultation, and see what a difference quality dentistry can make!

Early Patient Registration

Dental History

Medical History