Dr. Guy Spinner
16 Old Riverhead Road
Westhampton Beach, NY 11978
631.288.9000

Long Island Cosmetic Dentistry - LVI preferred dentist

Medical History Form


$25 OFF New Patient Exam If You Fill Out The Medical Form & Send To Us 24 Hours Before Your Apointment

Click Here To Download The Medical History Form


You may download the form and Fax to: 631-288-1800

E-mail the form to SmileSolutionsNews@Gmail.com

Or Simply click "SUBMIT" at the bottom of the below form once you fill it out

Primary Care Physician:
Phone #:
Are you currently taking any medications, including regular doses of aspirin?
If so, please list name and dosage
Are you aware of having an allergic reaction to any medication or substance?
If so, please list
Have you been under the care of a medical doctor during the past two years?
If so, for what
Have you seen an ear nose and throat doctor?
Name:
Have you seen a chiropractor?
Name:
Have you seen a neurologist?
Name:
Have you seen an orthodontist?
Name:
Do you take any pre-medication (antibiotics) for dental procedures?
Did some one refer you to the office?
Name:
Have you ever had a whiplash injury?
When:
Indicate below if you have had :
 
Congenital Heart Failure
Heart Murmur
Mitral Valve Prolapse
Artificial Heart Valve
Pacemaker
Stroke
Artificial Joint(s)
Liver Disease/Jaundice
Kidney Trouble
Trigeminal Neuralgia
HIV / AIDS
Neurological Disorders
Radiation/Chemotherapy
Psychiatric/Psychological
Asthma
Epilepsy / Seizures
Latex Sensitivity
Hepatitis
Tingling arms/fingers
Sickle Cell Disease
Bell’s palsy
Difficulty Swallowing
Acid Reflux
Diabetes
Insomnia/Frequent Waking
High Blood Pressure
Jaw Pain
Jaw Popping
Limited Opening
Congested Ears
Dizziness
Ringing Ears
Loose Teeth
Postural Problems
Clenching
Grinding
Facial Pain
Sensitive Teeth
Neck Ache
Headache
Does floss shred when you use it?
Does food pack or catch between your teeth?
Do you smoke or chew tobacco?
Do your gums bleed?
Does your breath concern you?
Do you feel sleepy during the day?
Do you use a CPAP/BiPAP machine or have performed a sleep study?
Have you ever been told you snore or stop breathing during sleep?
Do you have or had any disease, condition, syndrome, or problem not listed?
Women: Are you: Pregnant Nursing Take birth control pills

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the doctor of any change in my health or medication.

Name
Date of Birth
Email

 

Long Island Cosmetic Dentistry - Smile Solutions

631.288.9000

16 Old Riverhead Road
Westhampton Beach, NY 11978
Fax: 631.288.1800

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Disclaimer: Smile Solutions serves patients in the Long Island area including Westhampton, Hampton Bays, Brookhaven, Suffolk, Southampton and Riverhead.

This site only provides information about dental and cosmetic dental procedures including Crowns and Bridges, Dental Bonding, Dental Implants,

Smile Makeover, Teeth Whitening, Porcelain Veneers, Porcelain Fillings, Sedation Dentistry, Orthodontic Treatment, and TMJ

Treatment. This information is not meant to be taken as dental advice. Web site Design, Development and Optimization by Page1Solutions, LLC.

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