Are you allergic to:
Y N Y N
Local anesthetics ...................................................................................... Iodine.............................................................
Penicillin or other antibiotics ..................................................................... Hay fever/seasonal.........................................
Barbiturates, sedatives, or sleeping pills................................................... Metals..............................................................
Food........................................................................................................... Codeine or other narcotics...............................
Aspirin........................................................................................................ Animals............................................................
Latex.......................................................................................................... Other__________________________________________
Primary Insurance
Name of Insured:__________________________________________________
Relationship: ____ Self ____ Spouse ____ Child ____ Other
Insured Soc. Sec:__________________________________________________
Address _________________________________________________________
City ___________________________State __________ Zipcode____________
Insurance Co._____________________________________________________
Co._____________________________________________________________
DOB ________________ Employer __________________________________
Group # _______________________ ID # ______________________________
Name: Home Phone: Cell Phone:
_____________________________________________________________(_____)_______________(_____)__________________
Last First Middle
Email: Work Phone:
_____________________________________________________________(_____)_______________________________________
Address: City: State: Zip:
___________________________________________________________________________________________________________
Occupation: Employer: Height: Weight: DOB: Sex:
___________________________________________________________________________________________________________
SS# & Driver’s License #: Emergency Contact: Relationship: Home Phone: Cell Phone:
____________________________________________________________________(_____)_____________(_____)_____________
If you are completing this form for another person, what is your relationship to that person?
Your Name ___________________________________ Relationship___________________________________________________
Adult New Patient Form
Y N Y N
Do your gums bleed when you brush or floss? ...................................... Do you have ear aches or neck pains? ..........................
Are your teeth sensitive to cold, hot, sweets or pressure? ..................... Is your mouth dry? .........................................................
Does food or floss catch between your teeth? ....................................... Do you brux or grind your teeth? ....................................
Do you have sores or ulcers in your mouth? .......................................... Have you had any periodontal (gum) treatments?.........
Do you wear dentures or partials?.......................................................... Have you ever had orthodontic (braces) treatment? ......
Do you participate in active recreational activities? ................................ Is your home water supply fluoridated? ..........................
Have you had any problems associated with previous dental?............... Do you drink bottled or filtered water?.............................
Have you ever had a serious injury to your head or mouth?................... Are you currently having dental pain or discomfort?........
Do you have any clicking, popping or discomfort in the jaw?.................. Name of Previous Dentist_____________________________________
Date of your last dental exam:_________________________________ Address:___________________________________________________
What was done at the time?___________________________________ __________________________________________________________
Date of last dental x-rays: _______________ What is the reason for your dental visit today?__________________________________________________________
How do you feel about your smile?_______________________________________________________________________________________________________
Creating a Lifetime of Healthy Smiles
Do you have any of the following diseases or problems: Yes No
Active Tuberculosis.........................................................................................................................................................................................
Persistent cough greater than a 3 week duration...........................................................................................................................................
Cough that produces blood ............................................................................................................................................................................
Been exposed to anyone with tuberculosis.....................................................................................................................................................
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dr. Brunsden & Dr. Villa
732.679.2323
2455 Rt. 516 Old Bridge
New Jersey 08857
Medical Information
Primary Insurance Information Secondary Insurance Information
Name of Insured:___________________________________________ Name of Insured:________________________________________
Relationship: ___ Self ___ Spouse ___ Child ___ Other Relationship: ___ Self ___ Spouse ___ Child ___ Other
Insured Soc. Sec:___________________________________________ Insured Soc. Sec:_______________________________________
Address __________________________________________________ Address _______________________________________________
City __________________State __________ Zipcode______________ City ___________________State ___________ Zipcode_________
Insurance Co.______________________________________________ Insurance Co.___________________________________________
DOB ________________ Employer __________________________ DOB __________ Employer _______________________________
Group # ____________________ ID # __________________________ Group # ______________________ ID # _____________________
Insurance Information
Are you allergic to:
Y N Y N
Local anesthetics ...................................................................................... Iodine.............................................................
Penicillin or other antibiotics .....................................................................
Hay fever/seasonal.........................................
Barbiturates, sedatives, or sleeping pills................................................... Metals.
.............................................................
Food........................................................................................................... Codeine or other narcotics...............................
Aspirin........................................................................................................ Animals............................................................
Latex.......................................................................................................... Other__________________________________________
Dental Information
Y N
Are you now under the care of a physician? ........................................................ Physician Name: ____________________________________
Are you in good health?........................................................................................ Phone (____)______________ Fax (____)________________
Has there been any change in your general health within
the past year?.................................................................................................. AddressCity/State/Zip: _______________________________
Are you taking or have you recently taken any prescription or _________________________________________________
over the counter medicine(s)? .............................................................................. _________________________________________________
If so, please list all, including vitamins, natural or herbal
preparations and/or diet supplements:_________________________________
Any serious illness, operation or been hospitalized in the past 5 years?...............
If yes, what was the illness or problem?__________________________________________________________________________________________________
Y N Y N
Do you wear contact lenses? .............................................. Do you use controlled substances (drugs)?...........................
Have you had an orthopedic total joint Do you use tobacco (smoking, snuff, chew, bidis)?...............
replacement? (hip, knee, elbow, finger) .............................. If so, how interested are you in stopping?
Date: _____________ (Circle one) VERY / SOMEWHAT / NOT INTERESTED
If yes, have you had any complications?_____________ WOMEN ONLY Are you: Pregnant?
_____________________________________________ Number of weeks: ___________ Nursing? ...............
Are you taking or scheduled to begin taking Do you drink alcoholic beverages?.........................................
either of the medications alendronate (Fosamax®) How much in the last 24 hours? __________________
or risedronate (Actonel®) for osteoporosis or In the last week? ______________________________
Paget’s disease?..................................................................
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous
bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications
resulting from Paget’s disease, multiple myeloma or metastic cancer?..........................................................................................................
Date Treatment began: _____________________________________
Hay fever/seasonal.........................................
.............................................................
Y N
Artificial (prosthetic) heart valve...................
Previous infective endocarditis....................
Damaged valves in transplanted heart.......
Congenital heart disease (CHD)..................
Unrepaired, cyanotic CHD...........................
Repaired (completely) in last 6 months.......
Repaired CHD with residual defects............
Cardiovascular disease...............................
Angina ........................................................
Arteriosclerosis............................................
Congestive heart failure...............................
Damaged heart valves.................................
Heart attack.................................................
Heart murmur...............................................
Low blood pressure.....................................
High blood pressure....................................
Mitral valve prolapse....................................
Pacemaker...................................................
Rheumatic fever ..........................................
Rheumatic heart disease..............................
Abnormal bleeding.......................................
Anemia..........................................................
Blood transfusion..........................................
If yes, date:_______________________
Please mark if you’ve had any of the following:
Autoimmune disease......................
Rheumatoid arthritis........................
Systemic lupus erythematosus.......
Asthma............................................
Bronchitis........................................
Emphysema....................................
Sinus trouble...................................
Tuberculosis....................................
Cancer/Chemotherapy....................
Radiation Treatment........................
Chest pain upon exertion................
Chronic pain....................................
Diabetes Type I or II........................
Eating disorder................................
Malnutrition......................................
Gastrointestinal disease..................
G.E. Reflux/persistent
heartburn....................................
Ulcers..............................................
Thyroid problems............................
Stroke..............................................
Glaucoma.........................................
Hemophilia.......................................
AIDS or HIV infection.......................
Arthritis.............................................
Hepatitis, jaundice or liver disease.............
Epilepsy.......................................................
Fainting spells or seizures..........................
Neurological disorders................................
If yes, specify:_____________________
Sleep disorder.............................................
Mental health disorders..............................
Specify:___________________________
Recurrent Infections....................................
Type of infection:___________________
Kidney problems.........................................
Night sweats...............................................
Osteoporosis..............................................
Persistent swollen glands...........................
(in neck)
Severe headaches/migraines......................
Severe or rapid weight loss..........................
Sexually transmitted disease.......................
Excessive urination......................................
Has a physician or previous dentist
recommended that you take antibiotics
prior to your dental treatment?.....................
Y N
Y N
Name of physician or dentist making recommendation: __________________________________________ Phone: (_____)______________
Other Referral Source: ___________________________________________________________________
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health
history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth
above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian: _______________________________________________________________________________Date: ________________
Medical Information
Address _________________________________________________________
DOB ________________ Employer __________________________________
Hay fever/seasonal.........................................
.............................................................
