HomeNeighborhood Dentistry Neighborhood Dentistry Neighborhood Dentistry Chart # ____________________________________________________ FOR OFFICE USE ONLY PATIENT INFORMATION: Date: Patient Name: Last, First, MI (Preferred Name) Gender: Male Female Social Security # Birth Date Driver`s License # Phone (Home) (Work) (Cel) (E-mail) What is your preferred method of communication? Home Phone Work Phone Cel E-mail Address Apartment # City State ZIP Pharmacy phone E-mail I prefer to be addressed on correspondence as in person Spouse`s Name MARITAL STATUS: Married Separated Single Divorced Widowed Engaged Employer Occupation Bus. Phone In case of Emergency, call Cell Phone Address (Name of close relative NOT living at your home address.) Name Phone Address Whom may we thank for referring you? Name Phone Address Did you visit our web site?https://nycdental-dds.com Yes No DENTAL INSURANCE INFORMATION Do you have dental insurance? Yes No If yes: Name of Primary Carrier Address Group Insurance No ID # Is your treatment accident related? Yes No If yes: Date of Accident Attorney handling the accident (Name) (phone number) Do you have medical insurance? Yes No If yes: Name of Primary Carrier Address Group Insurance No ID # Signature Date: 275 Ave X, Brooklyn, NY, 11223 Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com www.nycdental-dds.com Do you have or have you ever had any of the following? Y N Condition Abnormal bleeding Blood disorders Anemia Hypoglycemia Sickle cell anemia Hemophilia Blood transfusion Leukemia High blood pressure Low blood pressure Fainting spells Pacemaker Mitral Valve Prolapse Angina pectoris Rheumatic fever Artificial heart valve Heart murmur Bacterial endocarditis Heart surgery Congenital heart defect Stroke Other heart ailment Lung disease Difficulty breathing/shortness of breath Allergies or Hay fever Respiratory disease Emphysema Asthma Tuberculosis Sinus trouble Intestinal disease Stomach/GI disorders Y N Condition Ulcers Colitis Anorexia or Bulimia Other eating disorder Frequent headaches Head Injury Psychiatric problems/Nervous disorder Epilepsy/Seizure Alzheimer`s disease Arthritis Rheumatism Prosthetic joint replacement Osteoporosis/Osteopenia Tumor or growth Cancer Radiation treatment Chemotherapy Cosmetic surgery Glaucoma Kidney problems/Disease/Dialysis Thyroid or Parathyroid disease Diabetes - Insulin dependent Diabetes - Oral medication Hepatitis, Liver disease (A/B/C) Venereal disease Alcohol abuse Drug abuse AIDS/ HIV positive Latex allergy Fever blister Xerostomia (dry mouth) Burning tongue MEDICATIONS Are you sensitive or allergic to any medications? Penicillin Yes No Sulfa Drugs Yes No Tetracycline Yes No Codeine Yes No Have you ever had penicillin? Yes No Do you have any tattoos or body piercing? Yes No Location? Does exposure to the sun cause you to break out? Yes No Do you wear contact lenses? Yes No Have you ever taken: Aspirin Coumadin Pradaxa Date: Please list any additional medications and reason for use: Yes No Medication: Dosage/Number of years Prescribing doctor Reason for use Medication: Dosage/Number of years Prescribing doctor Reason for use Medication: Dosage/Number of years Prescribing doctor Reason for use Signature Date: 275 Ave X, Brooklyn, NY, 11223 Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com www.nycdental-dds.com DENTAL HISTORY Have you ever had a local anesthetic? (Lidocaine, etc.) Yes No Have you ever had an unfavorable reaction to a local anesthetic? Yes No Have you had any serious trouble associated with any previous dental treatment? Yes No When was your last x-ray? When was your last dental treatment? Does dental treatment make you nervous? Yes No Have you ever had Nitrous Oxide Analgesia (gas) during dental treatment? Yes No MEDICAL HISTORY Personal Physician Telephone Do you have any Biomedical or tissue implants such as: Date Chin Breast Dental Knee Hip Heart Valve Craniofacial Do you use tobacco? Yes No Cigarette Pipe Cigar Chewing tobacco? If so, how often? Do you use alcohol? Yes No If so, how much? Do you use drugs? Yes No If so, what type and how much? Have you traveled abroad recently or experienced any health related symptoms after traveling abroad? Yes No Have you spent any extended period of time in foreign countries? Yes No Have you ever experienced diarrhea for extended periods of time? (2 to 3 months) Yes No (Women) Are you pregnant? Yes No (Women) Do you have any problems associated with your menstrual period? Yes No (Women) Are you going through menopause now or have you in the past? Yes No Please indicate stage: Now In past Year started Completed: Have you ever been treated by any of the following? Endodontist Periodontist Oral Surgeon Prosthodontist Orthodontist Cardiologist Plastic Surgeon Endocrinologist Psychiatrist/Psychologist Otolaryngologist (Ear, Nose,Throat) Name Address Phone Signature Date: 275 Ave X, Brooklyn, NY, 11223 Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com www.nycdental-dds.com Send form