Newton Street Dental, P - ProSites, Inc.



Newton Street Dental, P.C.

488 Newton Street

South Hadley, MA 01075

(413) 538-9604



PATIENT REGISTRATION AND HEALTH HISTORY

PLEASE COMPLETE THE FOLLOWING CONFIDENTAL INFORMATION

TODAY’S DATE__________________

YOUR NAME___________________________________ BIRTH DATE _____/______/_____ SOCIAL SECURITY # _____-_____-______

HOME PHONE ________________________ CELL PHONE _________________________ WORK PHONE _______________________

STREET ADDRESS _____________________________________________________________________________________________

CITY _______________________________________________ STATE ___________________ ZIP CODE ________________________

EMAIL ADDRESS ______________________________________________________________________________________________

IS YOUR MAILING ADDRESS DIFFERENT THAN YOUR STREET ADDRESS? □ YES □ NO, IF SO PLEASE FILL IN THE ADDRESS BELOW

MAILING ADDRESS ____________________________________________________________________________________________

CITY _______________________________________________ STATE ___________________ ZIP CODE ________________________

YOUR EMPLOYER __________________________________________________________ MAY WE CALL YOU AT WORK □ YES □ NO

MARITAL STATUS _________________________________ SPOUSE NAME _______________________________________________

IN CASE OF EMERGENCY, CONTACT __________________________________ PHONE NUMBER ______________________________

PERSON FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT ______________________________________________________________

WHO MAY WE THANK FOR REFERRING YOU? _______________________________________________________________________

INSURANCE

DENTAL INSURANCE ____________________________________________________ GROUP NUMBER ________________________

EMPLOYEE _____________________________________ BIRTH DATE _____/______/_____ SOCIAL SECURITY # _____-_____-______

UNION LOCAL ______________________________________________ SUBSCRIBER ID # ___________________________________

DO YOU HAVE A SECONDARY DENTAL INSURANCE? □ YES □ NO, IF SO PLEASE FILL IN THE INFORMATION BELOW

SECONDARY DENTAL INSURANCE __________________________________________ GROUP NUMBER ________________________

EMPLOYEE _____________________________________ BIRTH DATE _____/______/_____ SOCIAL SECURITY # _____-_____-______

UNION LOCAL ______________________________________________ SUBSCRIBER ID # ___________________________________

CONSENT: I hereby authorize this dental office to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctors to make a thorough diagnosis of the patient’s dental needs. I also authorize the doctors to perform any and all forms of treatment, medication, and therapy that may be indicated. I authorize and consent that the doctors may choose such assistance as deemed fit. I understand that the use of anesthetic agents embodies a certain risk. I understand that the responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand that a 1.5% finance charge (18% annually) will be added to any balance over 60 day.

PATIENT OR RESPONSIBLE PARTY SIGNATURE __________________________________________ DATE _______________________

RELATIONSHIP TO PATIENT _____________________________________________________________________________________

HEALTH HISTORY

Although dentists primarily treat the area in and around your mouth, it is important for us to know the facts relative to your present and past health.

Certain medications and health conditions could have an important interrelationship with the treatment that you will be receiving. The following

information is strictly confidential.

Patient’s name________________________________________________________ Occupation______________________________

Date of last physical examination: _____________ Physician’s name: _________________________________ Tel#_________________

Have you been under the care of a physician in the past two years? YES/NO Have you been hospitalized during that time? YES/NO

Preferred Pharmacy: ____________________________ Location: ________________________________________________________

Are you allergic to (i.e.; itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, local anesthetics, latex, metals, or any other medication? YES/NO

Describe: _____________________________________________________________________________________________________

Have you ever taken prescription Redux or Pondimin (Fen Phen)? YES/NO_______________________________________________

Have you ever had excessive bleeding requiring special treatment? YES/NO_______________________________________________

Circle any of the following that you have had or have at the present:

□ Heart Failure □ Kidney Disorders □ HIV Positive, ARC, AIDS

□ Heart Disease/Attack □ Ulcers □ Alcoholism/Drug Addiction

□ Angina Pectoris □ Use of Tobacco Products □ Eating Disorder

□ High Blood Pressure □ Emphysema □ Glaucoma

□ *Mitral Valve Prolapse □ Tuberculosis (TB) □ Cortisone Medicine

□ *Heart Murmur □ Asthma □ Hepatitis (Type: __________)

□ *Rheumatic Fever □ Sinus Problems □ Liver Disease

□ *Congenital Heart Lesions □ Chronic Cough □ Jaundice

□ Heart Pace Maker □ Allergies or Hives □ Blood Transfusion

□ Heart Surgery □ Diabetes □ Bleeding Disorder

□ Cancer (Type: ___________) □ Radiation Treatment □ Bruise Easily

□ Anemia □ Chemotherapy □ Cold Sores

□ Stroke □ Arthritis □ Herpes

□ Epilepsy or Seizures □ Fainting or Dizzy Spells □ *Any Type of Implant

□ Psychiatric Treatment □ Sickle Cell Disease □ *Any Type of Transplant

□ *Artificial Hip, Knee, or Joint □ Thyroid Disease

*Antibiotic medication may be required prior to your appointment.

* Have you taken antibiotics prior to dental appointments in the past? YES/NO Which antibiotic? _________________________

WOMEN: Are you pregnant? YES/NO Are you nursing? YES/NO Are you taking birth control pills? YES/NO

Please list all medications you are currently taking (including over the counter medications, vitamins, or herbal remedies):

_____________________________________________________________________________________________________________

Do you have any disease, condition, or problem not listed? YES/NO Please explain _________________________________________

_____________________________________________________________________________________________________________

To the best of my knowledge, all of the information on both sides of this form is true and correct. If there is any change in my health, or my

medications, I will inform the doctor prior to any treatment. I authorize treatment for the person named above and agree to pay all fees

and charges for such treatment. I understand that Newton Street Dental, PC will use my health history information as necessary for diagnosis

or treatment. I understand that antibiotics may reduce the effectiveness of birth control pills.

SIGNATURE: _______________________________________________________ Date: ________________________________

Newton Street Dental, P.C.

488 Newton Street, Suite 1

South Hadley, MA 01075

(413)538-9604-phone (413)534-3533-fax



DENTAL HISTORY

YOUR NAME _______________________________________________ DATE ____________________

It is important that we know about your dental history. Many things have a direct bearing on your dental health. I will review the questionnaire and discuss it with you in detail. Information you give is confidential and will not be released without your written consent.

Are you having any discomfort now? Y N Do you have: □ Frequent headaches □ Earaches

If so, describe: ____________________________ Are you often thirsty? Y N Is your mouth dry? Y N

Are your teeth sensitive? Y N Do you have any nasal obstruction? Y N

□ Cold □ Heat □ Sweets □ Chewing Are you aware of any oral lumps or swelling? Y N

When was your last dental treatment, describe: If so, describe: ____________________________________

_________________________________________ Have you ever had gum treatment? Y N

_________________________________________ Have you either lost or had teeth extracted? Y N

Have your teeth been straightened? Y N If so, please list teeth (location) and year lost or extracted:

How often do you brush? ____________________ _________________________________________________

How often do you floss? _____________________ Are any of your extracted or lost teeth replaced by:

Do you have bleeding gums? Y N □ Fixed bridge □ Implant □ Removable partial/full denture

Does food wedge between your teeth? Y N Have you ever had complications after extractions? Y N

An unpleasant taste in your mouth? Y N If so, describe: _____________________________________

If so, describe:_____________________________ Have you ever had a bad experience in a dental office? Y N

Do you grind or clench your teeth? Y N Describe: __________________________________________

When: ___________________________________ Do you feel nervous about having dental treatment? Y N

Have you ever had pain in or around your: Why? _________________________________________

□ Ears L R □ Jaw joints L R Are your teeth important to you? Y N

Have you had difficulty opening/closing your jaw? Do you want to keep your teeth for your lifetime? Y N

Y /N Describe: ___________________________ What is most important to you in regards to your teeth?

Do you hear popping, clicking or snapping noises? __________________________________________________

□ Chew □ Yawn □ Open wide __________________________________________________

If you have additional information about your dental history that you feel is important, or if you have additional concerns about your dental health, please use the remaining space to explain.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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