718-865-8111
105-46 Cross bay Blvd, Ozone Park NY 11417
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Doctors & Health.

Patient form

Patient information

Sex
  • Married
  • Widowed
  • Single
  • Minor
  • Separated
  • Divorced
  • Partnered

Dental insurance

Is patient covered by additional insurance?

Assignment and Release

I certify that I, and/or my dependents(s), have insurance coverage with and assign directly to all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am f i n a n c i a l l y responsible for all charges whether or not paid by insurance. I authorize the use of signature on all insurance submissions.


The above named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT
(Specify someone who does not live in your household.)

DENTAL HI STORY

Reason for today's visit
Place a mark on yes' or no' to indicate if you have had any of the following:

Bad breath

Bleeding gums

Blisters on lips or mouth

Burning sensation on tongue

Chew on one side of mouth

Cigarette, pipe, or cigar smoking

Clicking or popping jaw

Dry mouth

Fingernail biting

Food collection between the teeth
    

Foreign objects
   

Grinding teeth
   

Gums swollen or tender
   

Jaw pain or tiredness
   

Lip or cheek biting
   

Loose teeth or broken fillings
   

Mouth breathing
   

Mouth pain, brushing
   

Orthodontic treatment
   

Pain around ear
   

Periodontal treatment
   

Sensitivity to cold
   

Sensitivity to heat
   

Sensitivity to sweets
   

Sensitivity when biting
   

Sores or growths in your mouth
    


HEALTH HI STORY

Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Place a mark on yes' or no' to indicate if you have had any of the following:

Do you wear contact lenses?
Women:
Are you pregnant?
    
Taking birth control pills?   
    

Are you nursing?    
    

AIDS/HIV
   

Anemia
   

Arthritis, Rheumatism
   

Artificial Heart Valves
   

Artificial Joints
   

Asthma
   

Back Problems
   

Bleeding abnormally,
with extractions or surgery
   

Blood Disease
   

Cancer
   

Chemical Dependency
   

Chemotherapy
   

Circulatory Problems
   

Congenital Heart Lesions
   

Cortisone Treatments
   

Cough, persistent or bloody
   

Diabetes
   

Emphysema
   

Epilepsy
   

Fainting or dizziness
   

Glaucoma
   

Headaches
   

Heart Murmur
   

Heart Problems
   

Hepatitis Type
   

Herpes

High Blood Pressure
   

Jaundice
   

Jaw Pain
   

Kidney Disease
   

Liver Disease
   

Low Blood Pressure
   

Mitral Valve Prolapse
   

Nervous Problems
   

Pacemaker
   

Psychiatric Care
   

Respiratory Disease
   

Rheumatic Fever
   

Scarlet Fever
   

Shortness of Breath
   

Sinus Trouble
   

Skin Rash
   

Special Diet
   

Stroke
   

Swollen Feet or Ankles
   

Swollen Neck Glands
   

Thyroid Problems
   

Tonsillitis
   

Tuberculosis
   

Tumor growth on head or neck
   

Ulcer
   

Venereal Disease
   

Weight Loss, unexplained
   

Radiation Treatment
    



MEDICATIONS
List any medications you are currently taking and the correlating diagnosis:
ALLERGIES
Aspirin
Barbiturates
(Sleeping pills)
Codeine
Iodine
Latex
Local Anesthetic
Penicillin
Sulfa
Other

UPDATES (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?