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Address:
315 Cedar Lane
Teaneck, New Jersey 07666

Phone:
(201) 692-7737

Hours:
Mon & Wed: 8:00 AM–5:00 PM Tues & Thurs: 9:00 AM–6:00 PM Fri: 8:00 AM–3:00 PM

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Personal Payment Type
Salutation
Sex
Marital Status
Employment Status
Do you belong to a PPO or HMO?
Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?
Person Responsible For This Account
Student Status
Primary Dental Insured Party Gender
Primary Medical Insured Party Gender
Secondary Dental Insured Party Gender
Secondary Medical Insured Party Gender
Have you had any illness, operation, or been hospitalized in the past five years?
Do you have unleahed/recurrent injuries or inflamed areas, growths, or sore spots in or around your mouth?
Do you have a prosthetic joint/implant?
Have you had a heart valve replacement or vascular graft?
Stroke
Are you in good health?
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Rheumatic fever
Thyroid trouble
Damaged heart valves/mitral valve prolapse
Diabetes
Heart murmur
Low blood sugar
High blood pressure
Kidney Trouble
Low blood pressure
Are you on dialysis?
Chest pain/angina
Swollen ankles/arthritis/joint disease
Heart attack(s)
Stomach ulcers
Irregular heartbeat
Contagious diseases
Cardiac pacemaker
Sexually transmitted diseases
Heart surgery
Bronchitis, chronic cough
Are you immunosuppressed?
Asthma
Problems with immune system, possibly from medication/surgery, etc.
Hay fever/sinus problems
Delay in healing
Snoring/sleep apnea
A tumor or growth
Radiation therapy
Chronic fatigue/night sweats
Are you on a diet?
A history of alcohol abuse
A history of drug abuse
Contact lenses
Eye disease/glaucoma
Mental health problems/anxiety/depression
A removable dental appliance
Pain or clicking of jaws when eating
Malignant hyperthermia
If you are having surgery today, have you had anything to eat or drink in the last 6 hours?
Are you nursing?
Are you taking birth control pills?
Difficult breathing/other lung trouble
Tubercolosis
Emphysema
Do you smoke?
Do you use chewing tobacco?
Blood transfusion
Blood disorder such as anemia
Bruise easily
Bleeding tendency/abnormal bleeding
Hepatitis, jaundice, or liver disease
Infection mononucleosis
Gallbladder trouble
Fainting spells
Convulsions/epilepsy
Is there a possibility of pregnancy?
Any kind of medication, drug, pills
Blood thinners
What type of accident?
Local anesthetic
Penicillin
Other antibiotics
Sulfa drugs
Have you ever taken diet pills?
Sodium pentothal/Valium/other tranquilizers
Any natural product, herbal supplement, or homeopathic remedy?
Aspirin
Amoxicillin
Codeine or other narcotics
Any bone density medications or biphosphonates in the past 12 years?
Other medications
Tranquilizers, antidepressants, sleeping pills, and/or narcotics
Latex
Soy
Eggs/yolk
Sulfites
Do you have any known allergies?
Is there any condition concerning your health that the doctor should be told about?
Is this visit related to an accident
Do you wish to speak to the doctor privately about anything?
Cancer
Diabetes
Heart disease
Anesthesia problems
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