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1 Moorestown Smile Center 740 Marne Highway Suit 106 Moorestown, NJ Ph # : Patient Personal Information Title Last, First Address Nickname Marital Status Home # Cell # Student School Name Referral Type Age Sex Work # Drive Lic SSN Person responsible/guarantor for paying bills Title Nickname Last, First Address Marital Status Home # Cell # SSN Age Sex Work # Drive Lic Do you have Primary Dental Insurance No Do you have Secondary Dental Insurance No es No es No Group No/Name Insurance Name Phone # Employer Name Subscriber Last, First Subscriber Address Group No/Name Insurance Name Phone # Employer Name Subscriber Last, First Subscriber Address Relationship to Patient Relationship to Patient Subscriber ID Subscriber ID Patient Medical Information Allergic To N No Known Allergies N Aspirin N Barbiturates / Sleeping Pills N Codeine N Erythromycin N Iodine N Latex Rubber N Local Anesthetics N Metals N Anorexia N Arteriosclerosis N Arthritis N Asthma N Autoimmune Disease N Bladder Trouble N Blood Clotting Problems N Blood Transfusion N Bulimia N Bronchitis N Fainting Spells N Fever Blisters N Frequent Headaches N Frequently Dry Mouth / Sjogren N Gag Reflex N Gall Bladder Trouble N Hay Fever N Heart Attack N Heart Disease N Heart Murmur N Persistent Diarrhea N Premedicate N Radiation Treatment N Rheumatic Fever N Rheumatic Heart Disease N Rheumatoid Arthritis N Seizures N Sexually Transmitted Disease N Shortness of Breath N Skin Rash

2 N No Epinephrine N Penicillin N Cancer / Tumor or Growth N Cardiac Pacemaker N Hepatitis N Herpes N Sinus Trouble N Stomach Ulcers N Prior Hepatitis N Cardiovascular Disease N High Blood Pressure N Stroke N Sulfa Drugs N Chemotherapy N Hives N Thyroid Problems N Other Narcotics Check, if applicable N No Change Since Last Recorded N No Known Concerns or Issues N Abnormal Bleeding N AIDS/HIV Infection N Alcohol/Drug Abuse N Angina N Anemia N Ankles Swell N Chest Pain Upon Exertion N Color Blindness N Congenital Heart Defect N Contact Lenses N Congestive Heart Failure N Damaged Heart Valve N Diabetes N Emphysema N Environmental Allergies N Epilepsy N Jaundice N Joint Replacement N Kidney N Leukemia N Liver Disease N Low Blood Pressure N Lupus N Mental Health Problems N Mitral Valve Prolapse N Pacemaker Other N Tuberculosis N Unusual Weight Loss N Urinate Frequently N See Scanned Documents: Pt Note Dental Questionnaire Dental Questionnaire Name of previous Dentist Phone Date of your last cleaning Last exam date Date of your last full series x-rays Date of last cavity detection (bitewing) x-rays Do your gums bleed while brushing or flossing Are your teeth sensitive to hot, cold or sweets Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth Have you ever had burning of the tongue or cracking of the corners of your mouth

3 Do you chew/smoke tobacco in any form Have you had any head, neck or jaw injuries Do you notice popping, clicking or soreness of the jaws or points just in front of the ears Do you clench or grind your teeth Have you ever had orthodontic treatment If es, date of placement Do you wear dentures or partials If es, date of placement of dentures Are you happy with your dentures Are you having any specific problems with your teeth, gums, or mouth at this time Are you happy with your smile Do you have problems with teeth/fillings breaking Do you regularly use dental floss Do you have, or have you ever been told, that you have Pyorrhea (Periodontal Disease) Do you have difficulty in opening your mouth widely Do you have an unpleasant taste or odor in your teeth/mouth Does food catch between your teeth Do you want to learn to control your dental disease and retain your teeth Additional Comments

4 Any Disease, Condition or Problem not Listed Please list Medical Questionnaire Emergency Contact Emergency contact name Emergency contact phone Emergency contact relationship to patient Medical Questionnaire Family Physician Phone Are you currently under care of a Physician If es, what is the condition being treated Have you had any serious illness, operation or been hospitalized within the past 5 years If es, what illness or problem Are you currently taking any medication If es, what Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast) Have you ever taken the diet control drug Fen-Phen Do you use alcoholic beverages Do you smoke Women Only

5 Are you pregnant If es, what is your due date Are you currently nursing Do you have menstrual period problems Are you on hormone replacement therapy Are you on birth control pills / fertility drugs Additional Comments Any Disease, Condition or Problem not Listed Please list By signing below, I certify that all of the above information is true to the best of my knowledge. Patient/Guardian Signature Date

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