1777 Ocean Parkway, Brooklyn, NY 11223
718 998 9114
1755 Ocean Parkway, Brooklyn, NY 11223
718 998 3660
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( * ) Marks field are mandatory to fill out
Patient Name *
Date Of Birth *
PATIENT INFORMATION
R (leave Blank if you do not understand question) ( * ) Marks field are mandatory to fill out
Is your general health good? *
YesNo
Has there been a change in your health within the last year? *
Have you been hospitalized or had a serious illness in the last three years? *
If YES, why? *
Are you being treated by a physician now? *
For what? *
Date of last medical exam? *
Date of last Dental exam *
Have you had problems with prior dental treatment? *
Are you in pain now? *
HAVE YOU EXPERIENCED
Chest pain (angina)? *
Swollen ankles? *
Shortness of breath? *
Recent weight loss, fever, night sweats? *
Persistent cough, coughing up blood? *
Bleeding problems, bruising easily? *
Sinus problems? *
Difficulty swallowing? *
Diarrhea, constipation, blood in stools? *
Frequent vomiting, nausea? *
Difficulty urinating, blood in urine? *
Dizziness? *
Ringing in ears? *
Headaches? *
Fainting spells? *
Blurred vision? *
Seizures? *
Excessive thirst? *
Frequent urination? *
Dry mouth? *
Jaundice? *
Joint pain, stiffness? *
DO YOU HAVE OR HAVE YOU HAD
Heart disease? *
Heart attack, heart defects? *
Heart murmurs? *
Rheumatic fever? *
Stroke, hardening of arteries? *
High blood pressure? *
Asthma, TB, emphysema, other lung diseases? *
Hepatitis, other liver disease? *
Stomach problems, ulcers? *
Allergies to: drugs, foods, medications, latex? *
Family history of diabetes, heart problems, tumors? *
HIV+/AIDS *
Tumors, cancer? *
Arthritis, rheumatism? *
Eye diseases? *
Skin diseases? *
Anemia? *
VD (syphilis or gonorrhea)? *
Herpes? *
Kidney, bladder disease? *
Thyroid, adrenal disease? *
Diabetes? *
Psychiatric care? *
Radiation treatments? *
Chemotherapy? *
Prosthetic heart valve? *
Artificial joint? *
Hospitalization? *
Blood transfusions? *
Surgeries? *
Pacemaker? *
Contact lenses? *
ARE YOU TAKING
Recreational drugs? *
Drugs, medications, over-the-counter medicines (including Aspirin), natural remedies? *
Tobacco in any form? *
Alcohol? *
WOMEN ONLY
Are you or could you be pregnant or nursing? *
Taking birth control pills? *
ALL PATIENTS
Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain *
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.
Date *