Bard J. Levey, D.D.S. - Consolidated Patient Forms

1) Dental History
2) Health Questionnaire
3) Cosmetic Dental History (optional)

Health Questionnaire

Name Social Security # Date
Phone(Home) Cell Work
Home Address
City State Zip
Email Address
Date of Birth Marital Status
Physician's Name and Number
Employer
Name of Dental Insurance (if applicable)
Occupation
If insurance coverage is through your spouse, spouses name
Spouses date of birth and SSN(if applicable)
Referred By
Have you received medical treatment during the past year Y/N For what?
Have you had a skin reaction to jewelry?yes no
What medicines are you (your child) currently taking?
Women Are you pregnant?yes no     Taking birth control pills?yes no     Nursing? yes no
 
Please circle any of the following that you have had, or now have...
Heart Disease or Attack
A.I.D.S./HIV P0S
Diabetes
Angina Pectoris
Hepatitis A (Infectious)
Emphysema
High Blood Pressure
Hepatitis B (Serum)
Tuberculosis (TB)
Heart Murmur
Hepatitis C (non-A, non B)
Asthma
Rheumatic Fever
Blood Transfusions
Allergies or Hives
Congenital Heart Lesions
Drug Addictions
Cortisone Medication
Mitral Valve Prolapse
Hemophilia (Bleeding Problems)
Arthritis
Heart Pacemaker
Epilepsy or Seizures
Glaucoma
Heart Surgery
Liver Disease
Radiation Treatment
Artificial Joints
Psychiatric Treatment
Pain in Jaw Joints
Kidney Trouble
Alcoholism
Hay Fever
Stroke
Chemotherapy
Sinus Trouble
Anemia
Thyroid Disease
Ulcers
Venereal Disease
Other

 
Are you allergic to, or have you reacted adversely to any of the following?
Aspirin
Nitrous Oxide
Penicillin
Tetracycline
Metals
Latex
Codeine
Local Anesthesia
Erythromycin
Sedatives
Any Other?

Please give the name and telephone number of the closest relative or friend (not living with you) to contact in case of emergency
Name Phone
To the best of my knowledge, all answers are correct. I will notify Dr.Levey if any changes in my health or medication should occur. I consent to necessary treatment being performed on me by Dr. Levey and his staff, and also to the use of photos for educational and commercial purposes. Also, I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma; cardiac stimulation; temporary or rarely, permanent numbness; or muscle soreness. I understand that occasionally needles may break and require surgical retrieval.
↓ SIGN BELOW by using your MOUSE ↓


Patient's Name: Date:
 

Dental History

What prompted you to seek dental care at this time?

Why did you leave your previous dentist?

Where shall we send for your x-rays? Please include: Name, Address and Phone of receiving office. Please leave blank if none.


How would you describe the condition of your teeth and gums? Excellent Good Fair Poor
How long ago was your last thorough dental examination?
Do you have regular dental check-ups? yes no     How often?
Are you happy with the appearance of your teeth? yes no
Do you have any missing teeth? yes no
Are you aware of clenching or grinding your teeth? yes no
Do you usually have many cavities? yes no
Do you have any sensitivity in your teeth or gums? yes no
Do your gums feel tender, irritated, or swollen? yes no
How often do you use dental floss? yes no
Has any dental treatment been suggested that was not done? yes no
Do your gums bleed? yes no
Does food catch between your teeth? yes no
Do you avoid chewing or brushing in any part of your mouth? yes no
Have you lost or broken fillings? yes no
What concerns you most about dentistry? yes no
Do you have any concerns about your breath? yes no

How do you feel about dentistry in general?

If you could change anything about your teeth. what would it be?

It would be helpful if you would indicate below what things you are looking for most in choosing your dentist:
Explains things so that I understand them
Cares about me
Is aware of my financial concerns
Has a good appearance
Has a pleasant staff
Is gentle when working in my mouth
Has an attractive office
Keeps me and my family informed about office happenings and new trends in dentistry
Is on time for my appointment
Other
 

Cosmetic Dental History (optional)

LUMINEERS™ BY CERINATE® SMILE EVALUATION
A Simple Quiz to Help You Obtain the Smile You've Always Wanted
NO PAIN - YOU DON'T EVEN NEED AN ASPIRIN.

THE MOST SIGNIFICANT COSMETIC ADVANCEMENT...EVER!
Hold a mirror 12-14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, then answer the following questions. If you are not happy with the appearance of your teeth, ask your dentist how LUMINEERS can improve your smile.
  1. Do you like the appearance of your teeth and your smile?yes no
    If not, explain
  2. Are your teeth all in alignment (straight)?yes no
    If not, explain
  3. Do you have spaces that you don't like?yes no
    If yes, explain
  4. Do you like the color of your teeth?yes no
    If not, explain
  5. Do you like the shape of your teeth?yes no
    If not, explain
  6. Are your teeth... chipped or protruding or hidden ???
  7. Are your teeth wearing on the biting surfaces?yes no
    If yes, explain
  8. Are there old fillings or dental work you don't like looking at?yes no
    If yes, explain
  9. What would you like to change the most in the appearance of your teeth?
  10. How would you like your teeth to look?