Park Avenue Prosthodontics

New Patient Form

Please input the information requested before visiting our office. Please fill in as much information as posssible as this will expedite our ability to serve you at our offices. If this form is not completed on line new patients will be required to fill out this form upon thier first visit to our office.

PATIENT CONTACT INFORMATION (*required)

*Name

*Home Phone

*Address

*Cell Phone

Occupation

Business Phone

Date of last physical exam

*Email

PRESENT HEALTH

1. Do you consider yourself to be in good health

Yes

No

Do not know

 2. Are you presently under a physician's care?

Yes

No

Do not know

 3. Are you taking any medicine at the present time? *

Yes

No

Do not know

PAST ILLNESS, OPERATIONS

4. Have you ever had any major operations?

Yes

No

Do not know

5. Have you ever been seriously ill?

Yes

No

Do not know

6. Have you ever been hospitalized

Yes

No

Do not know

CARDIOVASCULAR

7. Has a doctor ever said you had a heart murmur or heart trouble?

Yes

No

Do not know

8. Do you get out of breath easily?

Yes

No

Do not know

9. Has a doctor ever said your blood pressure was too high or too low?

Yes

No

Do not know

10. As a child did you have Rheumatic fever, growing pains or twitching of the limbs?

Yes

No

Do not know

11. Are you subject to fainting spells?

Yes

No

Do not know

12. Have you ever had Rheumatic heart disease or Saint Vitus' dance?

Yes

No

Do not know

13. Are your ankles often badly swollen?

Yes

No

Do not know

14. Have you at times had severe nose bleeds

Yes

No

Do not know

15. Do you sleep with more than one pillow

Yes

No

Do not know

BLOOD

16. Have you ever had anemia?

Yes

No

Do not know

17. Have you ever had abnormal bleeding or severe pain following extraction of teeth or from a cut?

Yes

No

Do not know

18. Have you ever tested positive for HIV, or do you have AIDS?

Yes

No

Do not know

19. Do you bruise easily

Yes

No

Do not know

20. Are you a bleeder?

Yes

No

Do not know

ENDOCRINE

21. Have you ever had diabetes?

Yes

No

Do not know

22. Has any member of your family had diabetes?

Yes

No

Do not know

23. Do you have trouble with frequent boils?

Yes

No

Do not know

24. Have you ever taken thyroid tablets?

Yes

No

Do not know

25. Have you ever received treatment for any type of endocrine or glandular disorder?

Yes

No

Do not know

26. Did you reach puberty prior to age 16?

Yes

No

Do not know

27. Are you thirsty much of the time and do you drink a lot of liquids

Yes

No

Do not know

NERVOUS

28. Do you suffer frequent severe headaches?

Yes

No

Do not know

29. Have you ever had any severe pains of the face or head

Yes

No

Do not know

30. Do you usually sweat or tremble during examinations or questioning?

Yes

No

Do not know

31. Are you under tension?

Yes

No

Do not know

32. Do you consider yourself excessively nervous?

Yes

No

Do not know

33. Has a physician ever told you that you had epilepsy?

Yes

No

Do not know

34. Have you ever had a nervous breakdown?

Yes

No

Do not know

RESPIRATORY

35. Do you suffer from frequent colds, sore throats, or sinusitis?

Yes

No

Do not know

36. Have you ever had tuberculosis

Yes

No

Do not know

37. Have you had a chest X-ray within the last year?

Yes

No

Do not know

38. Have you a persistent cough?

Yes

No

Do not know

39. Do you breathe primarily through your mouth

Yes

No

Do not know

G.I. AND G.U.

40. Do you suffer from stomach trouble?

Yes

No

Do not know

41. Have you ever had yellow jaundice or hepatitis?

Yes

No

Do not know

42. Have you ever had liver or gall bladder trouble

Yes

No

Do not know

43. Do you have kidney or bladder trouble?

Yes

No

Do not know

44. Are you on any special type of diet?

Yes

No

Do not know

ALLERGIES

45. Are you sensitive or allergic to any particular medicine?(Aspirin, Antibiotics, Penicillin, Anesthetics, Novocain)

Yes

No

Do not know

46. Do you have asthma or hay fever?

Yes

No

Do not know

47. Have you ever had hives or a rash?

Yes

No

Do not know

48. Do you have an allergy?

Yes

No

Do not know

OTHER

49. Have you ever been treated for a skin disease?

Yes

No

Do not know

50. Are your joints often painful or swollen, do you have arthritis?

Yes

No

Do not know

51. Have you gained or lost much weight recently?

Yes

No

Do not know

52. Do you have frequent fever blisters, canker sores or have you ever had burning of the tongue or mouth?

Yes

No

Do not know

53. Have you ever had syphilis or gonorrhea

Yes

No

Do not know

54. Have you ever received X-ray or Radioactive Isotope treatment?

Yes

No

Do not know

55. Has a doctor ever told you that you had a tumor or cancer? ..........................................

Yes

No

Do not know

56. Have you ever had anesthesia?

Yes

No

Do not know

57. When was the last time you had any X-rays taken?

Yes

No

Do not know

FEMALES

58. Are you pregnant now or suspect you may be?

Yes

No

Do not know

59. Is your menstrual cycle regular

Yes

No

Do not know

60. Do you bleed excessively during your menstrual period

Yes

No

Do not know

61. Have you ever noticed any spotting with blood or bleed in between periods?

Yes

No

Do not know

62. Have you undergone or are you undergoing menopause, if so, are there any symptoms?

Yes

No

Do not know

DENTAL

63. Have you ever had an acute sore mouth

Yes

No

Do not know

64. Do you have frequent fever blisters on your lips or mouth

Yes

No

Do not know

65. Have you ever had burning of the tongue or cracking of the corners of your mouth?

Yes

No

Do not know

66. Do your gums bleed? When?

Yes

No

Do not know

67. Are you aware of a bad taste or odor in your mouth

Yes

No

Do not know

68. Are you troubled with frequent gum boils?

Yes

No

Do not know

69. Does your jaw ever get "out of joint

Yes

No

Do not know

70. Do you ever have pain opening or closing your mouth?

Yes

No

Do not know

71. Does your jaw ever "Click"?

Yes

No

Do not know

72. Did you ever wear braces for straightening your teeth?

Yes

No

Do not know

73. Have you ever had previous "gum treatments"?

Yes

No

Do not know

74.Are you bothered by tooth sensitivity?

Yes

No

Do not know

Are there any additional comments you would like to make concerning any recent illness, operations, medications, examinations, or your physical health in general?

INSURANCE INFORMATION IF APPLICABLE:

Social Security Number

Insurance Company Name

Employer

Insurance Company Address

Insurance Company Group

Insurance Company Phone

Insurance Company Policy

Todays's Date

  
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