765 Queen Anne Rd Teaneck, NJ 07666
201-836-4400
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Patient Personal Information
Gender
Male
Female
Person responsible/guarantor for paying bills
Gender
Male
Female
Do you have Primary Dental Insurance?
Yes
No
Do you have Secondary Dental Insurance?
Yes
No
Patient Medical Information
Allergic To (Check, if applicable)
No Known Allergies
Yes
No
Aspirin
Yes
No
Barbiturates / Sleeping Pills
Yes
No
Codeine
Yes
No
Erythromycin
Yes
No
Iodine
Yes
No
Latex Rubber
Yes
No
Local Anesthetics
Yes
No
Metals
Yes
No
No Epinephrine
Yes
No
Penicillin
Yes
No
Prior Hepatitis
Yes
No
Sulfa Drugs
Yes
No
Other Narcotics
Yes
No
Arteriosclerosis
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Autoimmune Disease
Yes
No
Bladder Trouble
Yes
No
Blood Clotting Problems
Yes
No
Blood Transfusion
Yes
No
Bulimia
Yes
No
Bronchitis
Yes
No
Cancer / Tumor or Growth
Yes
No
Cardiac Pacemaker
Yes
No
Cardiovascular Disease
Yes
No
Chemotherapy
Yes
No
Chest Pain Upon Exertion
Yes
No
Color Blindness
Yes
No
Frequent Headaches
Yes
No
Frequently Dry Mouth /Sjogren
Yes
No
Gag Reflex
Yes
No
Gall Bladder Trouble
Yes
No
Hay Fever
Yes
No
Heart Attack
Yes
No
Heart Disease
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Hives
Yes
No
Jaundice
Yes
No
Joint Replacement
Yes
No
Kidney
Yes
No
Leukemia
Yes
No
Rheumatic Fever
Yes
No
Rheumatic Heart Disease
Yes
No
Rheumatoid Arthritis
Yes
No
Seizures
Yes
No
Sexually Transmitted Disease
Yes
No
Shortness of Breath
Yes
No
Skin Rash
Yes
No
Sinus Trouble
Yes
No
Stomach Ulcers
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tuberculosis
Yes
No
Unusual Weight Loss
Yes
No
Urinate Frequently
Yes
No
Other
No Change Since Last Recorded
Yes
No
No Known Concerns or Issues
Yes
No
Abnormal Bleeding
Yes
No
AIDS/HIV Infection
Yes
No
Alcohol/Drug Alcohol
Yes
No
Angina
Yes
No
Anemia
Yes
No
Ankles Swell
Yes
No
Anorexia
Yes
No
Congenital Heart Defect
Yes
No
Contact Lenses
Yes
No
Congestive Heart Failure
Yes
No
Damaged Heart Valve
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Environmental Allergies
Yes
No
Epilepsy
Yes
No
Fainting Spells
Yes
No
Fever Blisters
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lupus
Yes
No
Mental Health Problems
Yes
No
Mitral Valve Prolapse
Yes
No
Pacemaker
Yes
No
Persistent Diarrhea
Yes
No
Premedicate
Yes
No
Radiation Treatment
Yes
No
See Scanned Documents: Pt Note
Yes
No
Oral Biphosphanates
Yes
No
No dental extractions
Yes
No
IV Biphophonates
Yes
No
Dental Questionnaire
Name of previous Dentist
Phone
Date of your last cleaning
Last exam date
Date of your last full series x-rays
Date of last cavity detection (bitewing) x-rays
Do your gums bleed while brushing or flossing ?
Are your teeth sensitive to hot, cold or sweets ?
Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth ?
Have you ever had burning of the tongue or cracking of the corners of your mouth ?
Do you chew/smoke tobacco in any form ?
Have you had any head, neck or jaw injuries ?
Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?
Do you clench or grind your teeth ?
Have you ever had orthodontic treatment ?
If Yes, date of placement
Do you wear dentures or partials ?
If Yes, date of placement of dentures ?
Are you happy with your dentures ?
Are you having any specific problems with your teeth, gums, or mouth at this time ?
Are you happy with your smile ?
Do you have problems with teeth/fillings breaking ?
Do you regularly use dental floss ?
Do you have, or have you ever been told, that you have Pyorrhea (Periodontal Disease)?
Do you have difficulty in opening your mouth widely ?
Do you have an unpleasant taste or odor in your teeth/mouth ?
Does food catch between your teeth ?
Do you want to learn to control your dental disease and retain your teeth ?
Additional Comments
Any Disease, Condition or Problem not Listed ? Please list
Medical Questionnaire
Emergency Contact
Emergency contact name
Emergency contact phone
Emergency contact relationship to patient
Medical Questionnaire
Family Physician
Phone
Are you currently under care of a Physician ?
If Yes, what is the condition being treated ?
Have you had any serious illness, operation or been hospitalized within the past 5 years?
If Yes, what illness or problem ?
Are you currently taking any medication ?
If Yes, what ?
Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia,
Skelid, Reclast)
Have you ever taken the diet control drug Fen-Phen ?
Do you use alcoholic beverages ?
Do you smoke ?
Women Only
Are you pregnant?
If Yes, what is your due date ?
Are you currently nursing ?
Do you have menstrual period problems ?
Are you on hormone replacement therapy ?
Are you on birth control pills / fertility drugs ?
Additional Comments
Any Disease, Condition or Problem not Listed ? Please list
By signing below, I certify that all of the above information is true to the best of my knowledge.
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