4 Vista Drive Great Neck, NY 11021 | (516) 773-4133
Welcome to our office... Let's get acquainted.
Patients Full Name:
Birthdate:
Name of both parents (or spouse, if married):
Home address:
City:
State:
Zip:
Home tel:
Cell:
Email:
Patient / Parent is:
Single
Married
Widowed
Separated
Divorced
Adult patient employed by:
Occupation:
Business address:
Phone:
Spouse of parent employed by:
Occupation:
Business address:
Phone:
Name of patient's dentist:
Phone:
Address:
Name of physician(s):
Phone:
Address:
Dental Insurance Coverage?
Yes
No
Policy Holder:
Dental Insurance Co.:
Policy No.:
Referred by:
Name & age of siblings/children:
Name of school attending:
Favorite sports / hobbies:
Please Answer Each Question
Poor health
Yes
No
Recent illness
Yes
No
Heart murmur
Yes
No
Nose obstruction
Yes
No
Heart or chest pain
Yes
No
Frequent swollen ankles
Yes
No
Facial x-ray treatment
Yes
No
Cortisone or ACTH
Yes
No
Bleeding tendency
Yes
No
Herpes
Yes
No
Hepatitis
Yes
No
Diabetes
Yes
No
Heart trouble
Yes
No
High blood pressure
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Lung disease
Yes
No
Asthma
Yes
No
Bronchitis
Yes
No
Rhumatic fever
Yes
No
Convulsions
Yes
No
HIV positive
Yes
No
AIDS
Yes
No
Anemia
Yes
No
Allergic to:
Penicillin
Yes
No
Metal
Yes
No
Latex
Yes
No
Local Anesthetic
Yes
No
Codeine
Yes
No
Aspirin
Yes
No
Other drugs
Yes
No
Must you sleep with your head on more than one pillow?
Yes
No
Have you ever been put to sleep for an operation?
Yes
No
Are you pregnant?
Yes
No
Are you under the care of a physician?
Yes
No
Do you require premedication at dental visits?
Yes
No
Have you ever responded unfavorably to medical or dental care?
Yes
No
Do you get short of breath after a little exertion?
Yes
No
Have you ever been hospitalized within the last 5 years?
Yes
No
Are you now taking medicine of any kind?
Yes
No
COVID-19 INFO
Are You Vaccinated?
Yes
No
COVID / Vaccine History
Remarks:
Medical problems:
Patient Validation:
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