areasontosmile.com (845) 457-5763
Masci, Hale & Wilson

New Patient Packet

Step 6

Summary

Patient Information

First Name:
Last Name:
Preferred Name:
Date of Birth:
Gender:
SS#:
Address Street:
Apt #:
City:
State:
Zip:
Contact #: Home:
Work:
Cell:
Email:

Financial Information

Insurance Plan:

Please have your Insurance Benefits Card available for verification

Employer:
Plan Holder (if other than self):
Date of Birth:
SS/ID #:
Relationship to patient:

Aesthetics

Are you happy with the appearance of your teeth?
Would you like your teeth to look whiter?
Would you like to see your smile look different?
Do you like the shape of your teeth?
Are you happy with the appearance of your lips?
Do you have discolored teeth that bother you?
Are you here for a specific reason?
If yes, please explain

Medical Info

1) Are you in good health?
2) Has there been any change in your general health within the past year?
3) Are you now under the care of a physician?
If so, what is the condition being treated?
Physician's Name
Address
City
State
Zip
Phone
4) Date of last physical examination
Date
5) Are you taking medicines, including non-prescription medicine?
If yes, what medicine?

Women Only

6) Are you pregnant?
7) Nursing?
8) Taking birth control pills?

Conditions — Do you have any of the following diseases or problems?

9) Abnormal bleeding
10) AIDS or HIV
11) Anemia
12) Arthritis
13) Rheumatoid arthritis
14) Asthma
15) Blood transfusion If yes, date
Date
16) Cancer / chemotherapy / radiation treatment
17) Cardiovascular disease
18) Angina
19) Arteriosclerosis
20) Artificial heart valves
21) Coronary insufficiency
22) Coronary occlusion
23) Damaged heart valves
24) Heart attack
25) High blood pressure
26) Inborn heart defects
27) Mitral valve prolapse
28) Pacemaker
29) Chest pain upon exertion
30) Chronic pain
31) Persistent diarrhea
32) Disease, drug or radiation-induced immunosuppression
33) Diabetes, if yes, specify
34) Dry mouth
35) Eating disorder Specify
Please specify
36) Epilepsy
37) Fainting spells or seizures
38) G.E. reflux
39) Glaucoma
40) Hemophilia
41) Hepatitis, jaundice or liver disease
42) Recurrent infections Specify
Please specify
43) Kidney problems
44) Low blood pressure
45) Mental health disorders Specify
Please specify
46) Migraines
47) Night sweats
48) Neurological disorders Specify
Please specify
49) Osteoporosis
50) Persistent swollen glands in neck
51) Respiratory problems. If yes, specify
52) Severe headaches
53) Severe or rapid weight loss
54) Sexually transmitted disease
55) Sinus trouble
56) Sleep disorder
57) Sores or ulcers in the mouth
58) Stroke
59) Systemic lupus erythematosus
60) Thyroid problems
61) Tuberculosis
62) Ulcers
63) Excessive urination
64) Any other diseases, condition or problem not listed above?
Please explain:

Conditions

65) Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? If so, what antibiotic and dose?
Antibiotic and dose
Name of physician or dentist
Phone
66) Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? If so, when was this operation done?
When
67) If yes. Have you had any complications or difficulties with your prosthetic joint?
Please explain

Allergies — Are you allergic or have you had a reaction to:

68) Local anesthetics
69) Aspirin
70) Penicillin or other antibiotics
71) Barbiturates, sedatives or sleeping pills
72) Sulfa drugs
73) Codeine or other narcotics
If yes responses, specify type or reaction
74) Latex
75) Iodine
76) Hay fever/seasonal
77) Animals
78) Food (specify)
Please specify
79) Other (specify)
Please specify

Signatures

Print Name
Signature