OHRS Registration Form

Your personal information will be kept in a confidential and secured database of subject information and will not be attached to the final data. Your information will not be shared with any individual not connected to an NYU Bluestone study.

Personal Information
First name		MI:	Last Name
Address		line 1
		line 2
City		State:	Zip code

Daytime Telephone #	( )
Evening Telephone #	( )
Cell Phone #	( )
E-mail Address	(optional)
Date of Birth	/ /		Age	years
	MM / DD / YYYY
Gender	(please check one)	male	female
Race/Ethnicity	(please check one)	Native American	Black/African American
		White/Caucasian	American Indian/Alaska Native
		Asian	Native Hawaiian/Other Pacific Islander
		Hispanic/Latino	Other:

Emergency Contact
Last + first Name			Relationship
Daytime Telephone #	( )
Below follow several questions about yourself and your health that will assist us in providing the best in health care for you and your family. You are not obligated to answer any of these questions. Please note that all results will be kept completely confidential.

Medical History
1.	Do you have or have you ever had high blood pressure?	Yes No
2.	Have you been told by a doctor that you have asthma? Asthma is a chronic respiratory disease, often arising from allergies, and accompanied by labored breathing, chest constriction, and coughing.	Yes No
3.	Have you ever been diagnosed with diabetes by a physician? Diabetes is a disease of altered blood sugar levels.	Yes No
4.	Do you have, or ever been diagnosed with Heart disease (heart murmur, rheumatic fever, other)?	Yes No
5.	Have you ever been diagnosed with HIV/AIDS by a physician?	Yes No
6.	Do you smoke? Smoking includes cigarettes, cigars, chewing tobacco and/or pipes.	Yes No
7.	Have you ever diagnosed with oral cancer by a dentist or a physician? Oral Cancer is a type of cancer that occurs as a sore on the lips that does not heal, a lump on the lip or in the mouth, throat or tongue, unusual bleeding, pain, or numbness in the mouth or difficulty with chewing or swallowing. The only way to know if you have had oral cancer is if you saw a doctor who diagnosed your with this specific type of cancer.	Yes No
8.	Do you constantly have a dry mouth?	Yes No
9.	TMJ (Jaw Joint Disorder): Have you experienced or are currently having pain anywhere in your face or in your jaw joint? Lower jaw joint located on the side of your head.	Yes No
10.	Do you have any of your natural teeth? If yes, please select one: I have less than 20 of my natural teeth I have more than 20 of my natural teeth	Yes No
11.	Do you wear dentures? If yes, please select one: I wear full dentures upper and lower plates I just wear an upper denture plate I do not wear any dentures	Yes No
12.	Do you have dental implants in your mouth? Dental implants are dental appliances (sterile titanium cylinders), which are placed in the upper and lower jawbones. Crowns, bridges, or dentures are attached to the implants to form stable restorations.	Yes No
13.	Do you have gingivitis? Gingivitis is a form of inflammation and infection that occurs in the gums. Classic signs of gingivitis include red, swollen and tender gums that may bleed when you brush.	Yes No
14.	Have you ever been told that you have periodontal disease? If yes, please select one: I am currently undergoing periodontal disease treatment I am not under any periodontal disease treatment Periodontal disease is a more advanced stage of chronic gum disease, including the presence of gum ulceration, gums that have receded or pulled away from your teeth, permanent teeth that are loose or separating, and recurring bad breath and/or an unpleasant taste in your mouth.	Yes No
15.	Have you ever participated in a research study at Bluestone Center?	Yes No
16.	Are you currently participating in a research study at Bluestone Center or any other center? If yes, please select one: I am currently participating in a Bluestone Study I am currently participating in a study at	Yes No
17.	Is there a particular study at Bluestone that you would like to participate at this time? Please describe:	Yes No

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