Hours Of Operation

Mon & Thurs: 8:00 am-6:00 pm Tues 10 am-8 pm Wed & Sat 8 am-2 pm Fri & Sun: Closed

Call Us

(973) 278-8181

Book Appointment

Your perfect smile is a click away!

Call Us

(973) 278-8181

Hours Of Operation

Mon & Thurs: 8:00 am-6:00 pm Tues 10 am-8 pm Wed & Sat 8 am-2 pm Fri & Sun: Closed

Book Appointment

Your perfect smile is a click away!

Patient Medical and Dental History

Patient Name:


Home Address:



Email:


Employer:


Insurance Co.:


Todays Date:


Date Of Birth:


Home Phone:


Cell Phone:


Business Phone:


SS#/SIN:


PATIENT MEDICAL HISTORY

Physician:


Office Phone:


Date of Last Exam:


 
1. Are you understand medical tratment now?
Yes   No

2. Have you ever been hospitalized for any surgical operation or serious illness?
Yes   No

3. Are you taking any medication(s) including non-prescription medicine?
Yes   No

If yes, what medication(s) are you taking?

4. Do you use tobacco?
Yes   No

5. Do you use alcohol or other drugs?
Yes   No

6. Are you wearing contact lenses?
Yes   No


7. Are you allergic to or have you had any reactions to the following ?
Local anesthetics:
Yes   No

Penicillin or other antibiotics:
Yes   No

Sulfa Drugs:
Yes   No

Barbiturates:
Yes   No

Sedatives:
Yes   No

Iodine:
Yes   No

Aspirin:
Yes   No

Other:
Yes   No



8. WOMEN ONLY:

a) Are you pregnent or think you may be pregnant?
Yes   No

b) Are you nursing?
Yes   No

c) Are you taking birth control pills?
Yes   No


9. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
Yes   No

10. Do You have or have you had any of the following?

High Blood Pressure:
Yes   No

Heart Attack:
Yes   No

Rheumatic Fever:
Yes   No

Swollen Ankies:
Yes   No

Fainting / Seizures:
Yes   No

Asthma:
Yes   No

Low/High Blood Pressure:
Yes   No

Epilepsy / Convulsions:
Yes   No

Leukemia:
Yes   No

Diabetes:
Yes   No

Kidney Diseases:
Yes   No

AIDS or HIV Infection:
Yes   No

Thyroid Problem:
Yes   No

Heart Disease:
Yes   No

Cardiac Pacemaker:
Yes   No

Heart Murmur:
Yes   No

Angina:
Yes   No

Anemia:
Yes   No

Emphysema:
Yes   No

Cancer:
Yes   No

Arthritis:
Yes   No

Joint Replacement or Implant:
Yes   No

Hepatitis / Jaundice:
Yes   No

Sexually Transmitted Disease:
Yes   No

Stomach Troubles / Ulcers:
Yes   No

Chest Pains:
Yes   No

Easily Winded:
Yes   No

Stroke:
Yes   No

Hay Fever / Allergies:
Yes   No

Tuberculosis:
Yes   No

Radiation Therapy:
Yes   No

Glaucoma:
Yes   No

Recent Weight Loss:
Yes   No

Liver Diseases:
Yes   No

Mitral Valve Prolapse:
Yes   No

Respiratory Problems:
Yes   No

Other:
Yes   No

PATIENT DENTAL HISTORY

1. Do your gums bleed while brusing or flossing?
Yes   No

2. Are your teeth sensitive to hot or cold liquids/foods?
Yes   No

3. Are your teeth sensetive to sweetor sour liquids/foods?
Yes   No

4. Do you feel pain to any of your teeth?
Yes   No

5. Do you have any sores or lumps in or near your mouth?
Yes   No

6. Have you had any head, neck or jaw injuries?
Yes   No

7. Have you ever experienced any of the following problems in your jaw?
a) Clicking?
Yes   No

b) Pain (joint, ear, side of face)?
Yes   No

c) Difficulty in opening or closing?
Yes   No

d) Difficulty in chewing?
Yes   No



8. Do you have frequent headaches?
Yes   No

9. Do you clench or grind your teeth?
Yes   No

10. Do you bite you lips or cheeks frequently?
Yes   No

11. Have you ever had any difficult extraction in the past?
Yes   No

12. Have you had any orthodontic treatment?
Yes   No

13. Have you ever had prolonged bleeding following extractions?
Yes   No

14. Have you ever had instruction on the correct method of brushing your teeth?
Yes   No

15. Have you ever had instructions on the care of your gums?
Yes   No



I certify that I have and understand the above information. To the best of my knowledge, the above question have been ....
I understand that providing incorrect information can be dangerous to my health.

Signature:
Date: