Orthodontist Orange County NY | New Patient Form

HEALTH HISTORY

Name

Home Phone

Cell Phone

Work Phone

Email*

Home Address

City

State

Zip

Date of Birth

Marital Status

Physician's Name and Number

Employer

Name of Dental Insurance (If applicable)

Spouses Name

Spouses Date of Birth and SSN

Referred By

Have you received medical treatment during the past year

Yes

For What

Currently taken medicines

Are you pregnant

Yes

Taking birth control pills?

Yes

Nursing?

Yes

Please tick any of the following that you have had, or now have...

Heart Disease or Attack

Heart Pacemaker

A.I.D.S./HIV P0S

Epilepsy or Seizures

Diabetes

Glaucoma

Angina Pectoris

Heart Surgery

Hepatitis A (Infectious)

Liver Disease

Emphysema

Radiation Treatment

High Blood Pressure

Artificial Joints

Hepatitis B (Serum)

Psychiatric Treatment

Tuberculosis (TB)

Pain in Jaw Joints

Heart Murmur

Kidney Trouble

Hepatitis C (non-A, non-B)

Alcoholism

Asthma

Hay Fever

Rheumatic Fever

Stroke

Blood Transfusions

Chemotherapy

Allergies or Hives

Sinus Trouble

Congenital Heart Lesions

Anemia

Drug Addictions

Thyroid Disease

Cortisone Medication

Ulcers

Mitral Valve Prolapse

Venereal Disease

Hemophilia (Bleeding Problems)

Other

Arthritis

Are you allergic to, or have you reacted adversely to any of the following?

Aspirin

Codeine

Nitrous Oxide

Local Anesthesia

Penicillin

Erythromycin

Tetracycline

Sedatives

Metals

Any Other?

Latex

DENTAL HISTORY

What prompted you to seek dental care at this time?

Why do you leave your previous dentist?

Where shall we send for your x-rays?

How would you describe the condition of your teeth and gums?

Excellent

Fair

Good

Poor

When was your last thorough dental examination?

Do you have regular dental check-ups?

Yes

How often?

Are you happy with the appearance of your teeth?

Yes

Do you have any missing teeth?

Yes

Are you aware of clenching or grinding your teeth?

Yes

Do you usually have many cavities?

Yes

Do you have any sensitivity in your teeth or gums?

Yes

Do your gums feel tender, irritated, or swollen?

Yes

Do you use dental floss?

Yes

Has any dental treatment been suggested that was not done?

Yes

Do your gums bleed?

Yes

Does food catch between your teeth?

Yes

Do you avoid chewing or brushing in any part of your mouth?

Yes

Have you lost or broken fillings?

Yes

What concerns you most about dentistry?

Yes

Do you have any concerns about your breath?

Yes

How do you feel about dentistry in general?

Great

Not great

No problem

I don't like it

If you could change anything about your teeth, what would it be?

It would be helpful if you would indicate below what things you are looking for most in choosing your dentist:

Explains things so that I understand them

Is gentle when working in my mouth

Cares about me

Has an attractive office

Is aware of my financial concerns

Keeps me and my family informed about office happenings and new trends in dentistry

Has a good appearance

Is on time for my appointment

Has a pleasant staff

Any other reason in choosing a dentist

EMERGENCY CONTACT DETAİLS

Please give the name and telephone number of the closest relative or friend (not living with you) to contact in case of emergency

Friend or Relative's Name

His/Her Phone Number

COSMETİC DENTAL HISTORY(Optional)

Hold a mirror 12-14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, then answer the following questions. If you are not happy with the appearance of your teeth, ask us how cosmetic dentistry can improve your smile.

Do you like the appearance of your teeth and your smile?

Yes

If not, explain

Are your teeth all in alignment (straight)?

Yes

If not, explain

Do you have spaces that you don't like?

Yes

If not, explain

Do you like the color of your teeth?

Yes

If not, explain

Do you like the shape of your teeth?

Yes

If not, explain

Are your teeth...

Chipped

Protruding

Hidden

Are your teeth wearing on the biting surfaces?

Yes

If yes, explain

Are there old fillings or dental work you don't like looking at?

Yes

If yes, explain

What would you like to change the most in the appearance of your teeth?

How would you like your teeth to look?

To the best of my knowledge, all answers are correct. I will notify Dr. Boyle if any changes in my health or medication should occur. I consent to necessary treatment being performed on me by Dr. Boyle and his staff, and also to the use of photos for educational and commercial purposes. Also, I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma; cardiac stimulation; temporary or rarely, permanent numbness; or muscle soreness. I understand that occasionally needles may break and require surgical retrieval.*

I accept the above declaration

Send a copy to yourself

This field should be left blank

Bronx

Newburgh

Health History Form

HEALTH HISTORY

DENTAL HISTORY

EMERGENCY CONTACT DETAİLS

COSMETİC DENTAL HISTORY(Optional)

(845) 863-0500

(917) 801 3600