Patient Biographical Information
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1 Patient Biographical Information Date: Name: Home Phone: ( ) Address: Bus Phone: ( ) City: Cell Phone: ( ) State: Zip Code: address: Soc. Sec. No.: Date of Birth: Sex: M F Height: Weight: Single Married Name of Spouse: Closest Relative: Phone: ( ) If you are completing this form for another person, what is your name and relationship to that person? How were you referred to Dr. DeRobertis? Nicholas C. DeRobertis, DMD Esthetic, Restorative & Implant Dental Medicine 354 Old Hook Road, Suite 202 Westwood, NJ Phone: WEB: 1
2 Policies & Forms Welcome to the Office Policy & Forms section of our website. Here, you will be able to review, download and print all the forms necessary prior to your first visit with Dr. DeRobertis. This may seem like a lengthy process; in reality, there is a plethora of information contained here to help you understand a little about us, yet, it is also how we will learn more about you, your medical and dental history and any particulars which are vital to your overall care. This is precisely why we have included these forms on our website -so that you can complete them in advance of your appointment when you are more relaxed. Please answer all questions to the best of your ability. Pediatric Patients (any child less than 18 years old) The MEDICAL HISTORY FORM for pediatric patients is located at the end of the NEW PATIENT section (last three pages). Please review, print and complete in lieu of the adult medical history forms at the beginning of this section. (All other forms contained in this section are still required to be reviewed and completed.) ***** Thank you ***** 2
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7 Health Information and History Today s Date: Patient s Name: Date of Birth: / / If you are completing this form for another person: Your name: Phone: Relationship: Emergency Contact: (If not listed above) Name: Phone: Relationship: Primary Physician: Phone: City & State: Date of last physical examination: Date of last blood test/work up: Other Physicians & Specialists Name: Specialty: Phone: City & State: Name: Specialty: Phone: City & State: D 4. Any history of taking or having taken a Bisphosphonate (Fosamax)? Yes No 1. Within the last 3 years, have you been hospitalized or had surgery? Yes No If Yes, please give reasons and dates: 2. Have you ever been instructed to take ANY medications or take ANY special precautions before any dental appointments*? Yes No If Yes, please explain: 3. Are you taking ANY drugs, medications, or treatments at this time? Yes No (If you brought a complete written list with you, please attach to this form) Prescribed: Over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medication, sleeping aids, etc): Vitamins, natural or herbal preparations and/or dietary supplements: Are you having or have you ever had radiation or chemotherapy treatments*? Yes No If Yes, for how long? Name of facility performing the treatment : 5. Are you allergic to or have you ever experienced an unusual reaction to: Latex Metals or jewelry Dental anesthesia (local) Fluoride Nitrous oxide (laughing gas) General anesthesia 6. Are you allergic to or have you ever had any reaction to any of the following drugs? Penicillin (or related drugs) Tranquilizers (Valium) Tetracycline Codeine Aspirin / Ibuprofen (Advil, Motrin, Nuprin) Keflex (Cephalexin) Sulfa drugs Iodine NSAID (Celebrex, Vioxx, Anaprox) Clindamycin (Cleocin) Erythromycin 7. Have you had an allergic reaction or unusual response to ANY other medications, drugs, pills, or treatments? Yes No If Yes, please list : Nicholas C. DeRobertis, DMD 354 Old Hook Road Suite 202 Westwood NJ
8 Health Information and History (page 2) Patient s Name: 8. Do you have, or have you ever had, any of the following? (Please check Yes or No for each question) Congenital heart defects Angina or chest pains Atherosclerosis Congestive heart failure Coronary artery disease Heart surgery If Yes, date & type Heart attack If Yes, date: Rheumatic heart disease Rheumatic fever Infective Endocarditis Heart valve(s) damage Mitral valve prolapse Artificial heart valve Pacemaker Stroke or CVA High blood pressure Low blood pressure Anemia Hemophilia or bleeding disorder Diabetes or blood sugar problems Hepatitis, jaundice, or other liver problems An organ transplant Women Only Are you pregnant If Yes, what is your due date: Are you presently nursing Are you taking hormone replacement therapy YES NO YES NO Asthma Hay fever, skin or food allergies or allergies in general Sinus problems Tuberculosis, emphysema or lung disorder Skin problems A sore or wound that bleeds easily or does not heal A thyroid problem or disease Arthritis Glaucoma or any eye diseases Epilepsy or other seizure disorder Any kidney problems Ulcers, acid reflux, or stomach problems A compromised immune system (Lupus, HIV, AIDS, radiation immune problem, etc.) An active sexually transmitted disease (STD) Any mental health issues Been treated for any psychiatric condition Excessive bleeding from any cut or incident Any artificial joint, joint surgery, or prosthesis If Yes, what joint or area: Any form of cancer Women Only Do you think you might be pregnant Are you using birth control medication Please use this space to indicate any other conditions, diseases, or medical problems, or is there ANY other information that you would like us to know about, or that we should be made aware of? If none, please indicate NONE below. CONSENT To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient s health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice. I understand there are no guarantees or warranties in health or dental care. Signature Date (Parent or guardian, if patient is a minor) Reviewed By: 8
9 Dental and Oral Health Information Patient s Name: Date: Do you have any specific dental problem or discomfort at this time? If yes, what type and how long: If you have had any of the following, please indicate who performed this treatment and approximate date: Periodontal (GUM) treatment or surgery Orthodontic treatment (BRACES) Dental Implants Any other type of oral surgery Do you have, have had or noticed any of the following in your head, neck or mouth? Teeth sensitive to: HOT, COLD, SWEETS Unpleasant taste or persistent bad breath Does food catch between your teeth Bleeding gums during brushing Red, swollen, tender, bleeding sore gums Gums that have pulled away from teeth Pus between teeth and gums Do you avoid any area when brushing or chewing Clench or grind your teeth Any lumps, swelling or swollen glands Sores, ulcers or rough spots in your mouth YES NO YES NO Teeth sensitive to: BITING PRESSURE Clicking, snapping or difficulty chewing Difficulty opening or moving your jaws Difficulty speaking or changes in your voice Difficulty moving your tongue or tongue-tied Loose or separating teeth Changes in the way your teeth fit together A color change in the tissues of your mouth Pain, tenderness, numbness or earaches Ulcers, acid reflux, or stomach problems Your Dental Health: How do you rate your overall dental health: GOOD FAIR POOR D How many times a DAY do you brush your teeth? Which devices/products do you currently use: How many times a WEEK do you FLOSS? Electric toothbrush: (type) ; Oral irrigation (Waterpik); Floss aids(threaders, etc); Interdental stimulators Home fluoride treatment/supplement (type) ; Mouth wash or rinses (type) If you have missing teeth, why haven t they been replaced? If you wear dentures: what type and for how long have you worn them? If you could change your smile, how would you like it changed? Have you ever had your teeth whitened or bleached? If so, when: Are you concerned about the finances to get your mouth in excellent condition? YES NO Are you frustrated that you always need something treated or repaired when you visit the dentist? YES NO Did you feel you would eventually wear artificial dentures? YES NO Complications from previous dentistry or tooth extractions? Please explain: Other dental conditions or serious trauma or injury to head, neck or mouth. Please explain: LAST DENTAL VISIT: Dentist Name & Address: 9 This form reviewed by:
10 Oral Health Risk factors Today s Date: Patient s Name: Date of Birth: 1. Do you smoke or have you EVER smoked? Yes No If NO, proceed to Question #2. The amount you are presently smoking (check all that apply): NONE(quit smoking completely LESS than 1 pack daily An occasional cigar An occasional cigarette 1-2 packs per day Cigars on a daily/regular basis A few cigarettes per day 2 or more packs per day A pipe on a daily/regular basis D 4. Do you have or have you ever had a substance abuse problem? Yes No If you have quit smoking, when did you quit? How many years have you or did you smoke? 2. Do you/have you EVER chew/chewed tobacco or use/used snuff or other similar substance? Yes No Are you still using SMOKELESS tobacco or snuff? Yes No If No, when did you quit? How long did you use smokeless tobacco? 3. Approximate average amount of alcoholic beverages presently consumed per week: None Less than 1/week 1-5 drinks 6-11 drinks Over 20 drinks 5. Do presently use any recreational drugs? Yes No 6. Do you have or have you ever had an eating disorder? Yes No 7. Do you have or have you ever had head, neck or mouth piercings? Yes No Other than ears, please list : 8. Do you have or have you ever been informed that you have been infected with an oncogenic strain (possible cancer-causing) of the Human Papilloma Virus (HPV)? Yes No 9. Please list your history or any family member s history of cancer: 10. Other concerns and considerations: CONSENT To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above-named individual until further notice. I understand there are no guarantees or warranties in health or dental care. Signature (parent or guardian, if minor) Date 10 Reviewed By:
11 Nicholas Corrado DeRobertis, DMD Esthetic, Restorative & Implant Dental Medicine INFECTION CONTROL We take great pride in providing our family of patients with the latest protocols to ensure their safety in the dental office setting. Our infection control procedures strictly adhere to those guidelines recommended by The Center for Disease Control (CDC) and The Occupational Safety and Hazard Administration (OSHA). We utilize the proper personal protective equipment; barrier protection; instrument processing and sterilization and patient education, so that we can be assured that our patients (and our staff) are well-guarded against the potential transmission of infectious agents. We utilize latex-free disposables as much as possible. Latex-free also eliminates any potential latexinduced allergic reactions. Anything that is NOT disposable is STERILIZED. Autoclave sterilization occurs after biofilm is removed via ultrasonic cleaning in an antimicrobial solution. Handpieces (drills) are also sterilized, however they are put through a pre-sterilization cleaning protocol in which they are mechanically purged with disinfecting solution and lubricant. Although pre-treatment mouth rinses with antimicrobials (like Listerine) significantly reduce the amount of oral microflora, another method of reducing the numbers of harmful organisms in the dental office setting is to refrain from elective procedures when patients are battling an infection that can spread microorganisms through aerosol formation. Therefore, it is also part of our infection control policy to not perform elective treatment on patients who are battling any type of communicable infections like measles, chicken pox, strep-throat or other conditions resembling an upper respiratory infection, the common cold, influenza, recurrent herpes labialis, or any other condition in which the airborne spread (or direct contact) of microorganisms can pose a potential risk to other patients or staff. Therefore, it is mandatory that our patients adequately advise us if they are suffering from any of these temporary conditions so we can alter their appointments until after they have recovered from these maladies. Dr. DeRobertis is also a member of OSAP, The Organization for Safety and Asepsis Proceduresa unique group of dental practitioners, allied healthcare workers, industry representatives, and other interested persons with a collective mission to promote infection control and related science-based health and safety policies and practices. OSAP supports this commitment to the dental workers and the public through quality education and information dissemination. If you have any questions, would like us to review our infection control procedures or care to have a tour of our infection control and sterilization procedures, we would welcome this opportunity to share our commitment to safety with you. 354 Old Hook Road Westwood, NJ
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15 Nicholas DeRobertis, DMD 354 Old Hook Road, Suite 202 Westwood, NJ ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. {Please Print Name} {Signature} {Date} For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002). 15
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