Call 908-200-7007 | Fax 908-735-6651 | Email Us Here | 1484 Rt 31 N, Annandale, NJ 08801
Medical history form2018-08-03T01:45:48+00:00

Patient Forms

Medical history form

Please download and print the following two documents. Bring the signed forms to your first appointment.

Also complete the medical history form below, and it will be sent directly to us.


 

 

 

 

 

 

 

 
 
 
 

Patient Medical History


 

 

 
 

 

 

 
 

 
 

 
 

 
 

 
 

  
 

9. Do you have or have you had any of the following?
 

 
 

10. Are you allergic to or have you had any reactions to the following:
 

  
 

11. Women only:
 
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?
 
 

Patient Dental History

 

 
  
 
 
Do you have or have you had any of the following?
 
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold liquids/foods?
Are you teeth sensitive to sweet or sour liquids/foods?
Do you feel pain to any of your teeth?
Do you have any lumps or sores in or near your mouth?
Have you had any head, neck, or jaw pain?
Have you ever experienced any of the following problems in your jaw?
Clicking
Pain (joint, ear, side of face)
Difficulty in opening or closing
Difficulty in chewing?
Do you have frequent headaches?
Do you clench or grind your teeth?
Have you ever had any difficult extractions in the past?
Have you ever had any prolonged bleeding following extractions?
Have you ever had any orthodontic treatment?
Do you wear dentures or partials?
If yes, please date of placement?
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Have you ever had Botox?
Do you like your smile?
 
 

 

Sleep Screening Questionnaire

 
Have you ever been diagnosed with obstructive sleep apnea (OSA)?
Are you currently being treated for OSA?
Are you aware of a family history of OSA
 
Epworth Sleepiness Scale

 
0= I would never doze
1= I have a slight chance of dozing
2= I have a moderate chance of dozing
3= I have a high change of dozing
 
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g. a theatre or meeting)
As a passenger in a care for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly in a lunch without alcohol
In a car while stopped for a few minutes in traffic
 
 

 

Authorization and Release

 

 
 
 


 
 
 
 
 

Call Now
908-200-7007

1484 NJ-31
Annandale, NJ
08801

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