Park Avenue Prosthodontics

ONLINE FORM

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

Office Locations: