Date:

Last Name:
First Name: Middle Initial:
Address:
City:
State:
Zip:
eMail:
Home phone:
Work phone:
Occupation: SSN:
Date of Birth: Height :
Sex: Weight:


Marital Status:
Name of Spouse/Partner:
Closest Relative: Phone:
 
If you are completing this form for another person, what is your relationship to that person?


Employer:

Referred by:
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
  1. Are you in good health? yes no

  2. Has there been any change in your general health within the past year? yes no

  3. My last physical examination was on

  4. Are you now under the care of a physician? yes no
    If so, what is the condition being treated?

  5. The name and Address of my physician(s) is:


  6. Have you had any serious illness, operation, or been hospitalized in
    the past 5 years?     yes no
    If so, what was the illness or problem?

  7. Are you taking any medicine(s) including
    non-prescription medicine     yes no
    If so, what medicine(s) are you taking?

  8. Do you have or have you had any of the following diseases or problems?
    1. Damaged heart valves or artificial heart valves: yes no
      (including heart murmur or rheumatic heart disease)
    2. Cardiovascular disease: yes no
      (including heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
      a. Do you have chest pain upon exertion? yes no
      b. Are you ever short of breath after mild exercise or when
      lying down?       yes no
      c. Do your ankle swell? yes no
      d. Do you have inborn heart defects? yes no
      e. Do you have a cardiac pacemaker? yes no


    3. Allergy: yes no
    4. Sinus trouble: yes no
    5. Asthma or hay fever: yes no
    6. Fainting spells or seizures: yes no
    7. Persistent diarrhea or recent weight loss: yes no
    8. Diabetes: yes no
    9. Hepatitis, jaundice or liver disease: yes no
    10. Thyroid problems: yes no
    11. Respiration problems, emphysema, bronchitis, etc: yes no
    12. Aids or HIV infection: yes no
    13. Stomach ulcer or hyperacidity: yes no
    14. Kidney trouble: yes no
    15. Tuberculosis: yes no
    16. Persistent cough or cough that produces blood: yes no
    17. Persistent swollen glands in neck: yes no
    18. Low blood pressure: yes no
    19. Sexually transmitted disease: yes no
    20. Epilepsy or other neurological disease: yes no
    21. Problems with mental health: yes no
    22. Cancer: yes no
    23. Problem on immune system: yes no


  9. Have you had abnormal bleeding? yes no
    A. Have you ever required a blood transfusion?     yes no

  10. Do you have any blood disorder? yes no

  11. Have you ever had any treatment for a tumor or growth? yes no

  12. Are you allergic or have you had a reaction to:
    A. Local anesthetics:     yes no
    B. Penicillin or other antibiotics:     yes no
    C. Sulfa drugs:     yes no
    D. Barbiturates, sedatives, or sleeping pills:     yes no
    E. Aspirin:     yes no
    F. Iodine:     yes no
    G. Codeine or other narcotics:     yes no
    H. Other:     yes no

  13. Have you had any serious trouble associated with any previous
    dental treatment?     yes no
    If so, explain


  14. Do you have any disease, condition, or problem not listed above that you think I
    should know about?     yes no
    If so, explain


  15. Are you wearing contact lenses? yes no

  16. Are you wearing removable dental appliances? yes no

  17. Do you smoke? yes no
    If yes, how much?

  18. Do you drink alcoholic beverages? yes no
    If yes, how much and what type?



    Women
  19. Are you pregnant? yes no

  20. Do you have any problems associated with your menstrual period? yes no

  21. Are you nursing? yes no

  22. Are you taking birth control pills? yes no


Chief Dental Complaint:


Any significant dental history we should know about?


If you would rather mail us this form, simply fill out each field and then print this page by selecting the Print option on your File menu otions above. Then sign the form and mail it to the address below.

    29 WEST DENTAL ASSOCIATES
    29 West 57th Street, 6th Floor
    New York, N.Y. 10019
    Ph (212) 838-2900
    Fax (212) 935-4703


I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.


__________________________________________
Signature of Patient