``````` NORTH AND CENTRAL NEW JERSEY
PERIODONTICS & IMPLANTOLOGY, L.L.C.
I have taken Phen-Fen (diet medication)
ANTHONY T. CHIN, D.D.S.
100 Town Center Drive
Warren, New Jersey 07059
Tel: (908) 222-3337
NJ Periodontal Specialty Permit #3925
MEDICAL HEALTH QUESTIONNAIRE
Name:
Phone: (H)
(Cell):
(E-mail):
(W)
Address:
Date of Birth:
Marital Status:
State:
Gender:
Social Security:
-
Name of Spouse:
-
Occupation:
Height:
Closest Relative:
Zip:
Weight:
His/Her Telephone:
Referred By:
Yes
1. How do you estimate your general health:
Good
Fair
No
Poor
2. Has there been any change in your general health within the past year? . . . . . . . . . . . . . . .
3. Are you now under the care of a physician? . . . . . . . . . . . . . . . . . . . . . . . . .
a. If so, what is the condition being treated?
b. Physician’s Name, Address and Telephone
4. Have you had any serious illness or operation? . . . . .
5. Do you have (or have had) any of the following:
Rheumatic fever
Congenital heart defects (Heart murmur)
Heart attack, stroke, problems with circulation
Diabetes - Type-I / Type-II
High or Low blood pressure
Hepatitis, jaundice or liver problems
Fainting spells, seizures, or epilepsy
Arthritis
Glaucoma
Blood transfusion
6. Have you ever experienced any of the following:
Chest pain following exertion?
Shortness of breath after mild exercise?
Swelling of your ankles?
Sleep on more than 2 pillows?
Bruise easily?
7. Are you taking any medication, drugs or pills? . . . .
If so, what drugs are you taking:
. . . . . . . . . . . . . . . . . . .
.
Stomach ulcers / Gastric problems
Allergies or Hay fever
Cancer or Tumor
Kidney problems
Tuberculosis
Asthma
Sinus problems
Anemia
Psychiatric treatment
Sex transmitted disease (syphilis, gonorrhea, AIDS)
Are you frequently thirsty?
Do you urinate (pass water) more than 6 times a day?
Have shortness of breath when lying flat?
Experience persistent cough or have coughed up blood?
Bleeding after tooth extraction, surgery or trauma?
. . . . . . . . . . . . . . . . .
Yes
No
9. Have you unintentionally gained or lost more than 10 pounds in the past year? . . . . . . . . . . .
10. Have you ever had surgery or radiation treatment of your head or neck? . . . . . . . . . . . . .
11. Are you taking any of the following:
Antibiotics or sulfa drugs
Antihistamines
Anticoagulants (blood thinners)
Aspirin
Medicine for high blood pressure
Insulin, tolbutamide (Orinase), or similar drugs
Cortisone (steroids)
Digitalis or drugs for heart problems
Tranquilizers
Nitroglycerin
Oral contraceptives or other hormonal therapy
Other:
12. Women:
Are you pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you have any problems associated with your menstrual cycle? . . . . . . . . . . . . . . .
Are you nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Have you experienced any of the following:
Tooth ache
Sensitivity to hot, cold or sweets
Bad breath
Collection of food between teeth
Bleeding gums
Dissatisfied with appearance of teeth
Loose teeth / fillings
Sores or growths in your mouth
Clenching / grinding of teeth
Clicking or popping of the jaw
Problems with dentures
TMJ problems
14. What is the name of your current Dentist:
8. Have you ever had any unusual reaction to any medication? . . . . . . . . . . . . . . . . . .
If so, what medications caused problems:
The above information is accurate and complete to the best of my knowledge. My medical history was reviewed
during my examination, and I will not hold my dentist or any member of his staff responsible for any errors or
omissions that I may have made in the completion of this form.
In accordance to HIPPA, I authorize Dr. Chin to provide my insurance company(s), claim administrator(s), and
consulting health care professionals, information concerning health care, advice, treatment or supplies provided.
This information will be used exclusively for the purpose of evaluating and administering claims for benefits.
I give Dr. Chin’s office permission to contact
me or leave messages:
Date:
Signature:
Date:
Dentist Signature:
on my cell phone
at my home residence
at my place of business
by e-mail
Revised 9/24/13
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