Dental Specialists of
South Loop

PATIENT REGISTRATION



 


Responsible Party (if someone other than the patient)















Patient Information










 















Primary Insurance Information














Secondary Insurance Information














MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?
 

Are you on a special diet?
 

Do you use tobacco?

Do you use controlled substances?

Women: Are you

Pregnant/Trying to get pregnant?  
Taking oral contraceptives?  
Nursing?  

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther

Do You have,or have you had,any of the following?

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problem

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores/Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart Pace Maker

Heart Trouble/Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

Have you ever had any serious illness not listed above?     

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.


Your Smile. Your Health. Our Commitment.

Do not wait, contact us today and find out more

Schedule an Appointment

South Loop Dental Specialists

850 South Wabash, Suite 240
Chicago, IL 60605

312-356-4700