Ramtown Dental
 
Experience Positive Personalized Care
ramtowndental@gmail.com
 
 
CALL US TODAY! 732-206-0408
137 Newtons Corner Rd, Howell, NJ 07731
 
 
 
 
 
 

Form

 
Patient Information
 
 
Sex:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dental Insurance
 
Is Patient Covered by additional insurance?
 
 
 
 
 
 
 
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with __________________________________________________ and assign directly to
Dr.
If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the gate signed below.
 

PHONE NUMBERS
 
 
 
 
 
 
 
 
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
 
 
 
 
 
 

DENTAL HISTORY
 
Place a mark on "yes" or "no" to indicate if you have had any of the following:
 
Bad Breath
 
 
 
 
Bleeding Gums
 
 
 
 
Blisters on lips or mouth
 
 
 
 
Burning sensation on tongue
 
 
 
 
 
Chew on one side of mouth
 
 
 
 
Cigarette, pipe, or cigar smoking
 
 
 
 
Clicking or popping jaw
 
 
 
 
Dry mouth
 
 
 
 
Fingernail biting
 
 
 
 
Food collection between the teeth
 
 
 
 
Foreign objects
 
 
 
 
Grinding teeth
 
 
 
 
Gums swollen or tendor
 
 
 
 
Jaw pain or tiredness
 
 
 
 
Lip or cheek biting
 
 
 
 
Loose tooth or broken fillings
 
 
 
 
 
Mouth breathing
 
 
 
 
Mouth pain, brushing
 
 
 
 
Orthodontic treatment
 
 
 
 
Pain around ear
 
 
 
 
Periodontal treatment
 
 
 
 
Sensitivity to cold
 
 
 
 
Sensitivity to heat
 
 
 
 
Sensitivity to sweets
 
 
 
 
Sensitivity when biting
 
 
 
 
Sores or growths in your mouth
 
 
 
 

HEALTH HISTORY
 
 
 
 
Have you ever used a bisphosphonate? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
 
 
 
 
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (doxfonfluramine).
 
 
 
Place a mark on "yes" or "no" to indicate if you have had any of the following:
 
 
AIDS/HIV
 
 
 
 
Anemia
 
 
 
 
Arthritis, Rheumatism
 
 
 
 
Artificial Heart Valvos
 
 
 
 
Artificial Joints
 
 
 
 
Asthma
 
 
 
 
Back Problems
 
 
 
 
Bleeding abnormally, with extractions or surgery
 
 
 
 
Blood Disease
 
 
 
 
Cancer
 
 
 
 
Chemical Dependency
 
 
 
 
Chemotherapy
 
 
 
 
Circulatory Problems
 
 
 
 
Congenital Heart Lasions
 
 
 
 
Cortisone Treatments
 
 
 
 
Cough, persistent or bloody
 
 
 
 
Diabetes
 
 
 
 
Emphysama
 
 
 
 
Do you wear contact lenses?
 
 
 
 
 
Epilepsy
 
 
 
 
Fainting or dizziness
 
 
 
 
Glaucoma
 
 
 
 
Headaches
 
 
 
 
Heart Murmur
 
 
 
 
Heart Problems
 
 
 
 
 
Hepatitis Type
 
 
 
 
 
 
Herpes
 
 
 
 
High Blood Pressure
 
 
 
 
Jaundice
 
 
 
 
Jaw Pain
 
 
 
 
Kidney Disease
 
 
 
 
Liver Disease
 
 
 
 
Low Blood Pressure
 
 
 
 
Mitral Valve Prolapsa
 
 
 
 
Nervous Problems
 
 
 
 
Pacemaker
 
 
 
 
Psychiatric Care
 
 
 
 
Radiation Treatment
 
 
 
 
 
Respiratory Disease
 
 
 
 
Rheumatic Fever
 
 
 
 
Scarlet Fever
 
 
 
 
Shortness of Breath
 
 
 
 
Sinus Trouble
 
 
 
 
Skin Rash
 
 
 
 
Special Diet
 
 
 
 
Stroke
 
 
 
 
Swollen Feet or Ankles
 
 
 
 
Swolen Neck Glands
 
 
 
 
Thyroid Problems
 
 
 
 
Tonsillitis
 
 
 
 
Tuberculosis
 
 
 
 
Tumor or growth on head or neck
 
 
 
 
Ulcer
 
 
 
 
Venereal Disease
 
 
 
 
Weight Loss, unexplained
 
 
 
 
WOMEN:
 
 
Are you pregnant?
 
 
 
 
Taking birth control pills?
 
 
 
 
 
 
Are you nursing?
 
 
 
 

 
MEDICATIONS
List any medications you are currently taking and the correlating diagnosis:
 
ALLERGIES