ID:
Chart ID:
First Name:
Last Name:
Middle Initial:
Patient Is Policy HolderResponsible Party
Preferred Name:
Address:
Address 2:
City, State, Zip:
Pager:
Home Phone:
Work Phone:
Ext:
Cellular:
Birth Date:
Soc Sec:
Drivers Lic:
Responsible Party is also a Policy Holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder
City:
State, Zip:
Sex:
MaleFemale
Marital Status:
MarriedDivorcedSeparatedWidowed
Age:
Soc. Sec:
E-mail:
I would like to receive correspondences via e-mail
Section 2
Employment Status:
Full TimePart TimeRetired
Student Status:
Full TimePart Time
Medicaid ID:
Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
Pref. Hyg.:
Section 3 Referred by: Previous Dentist: Emergency Contact: Emergency Contact #:
Name of Insured:
Relationship to Insured:
SelfSpouseChildOther
Insured Soc. Sec:
Insured Birth Date:
Employer:
City,State,Zip:
Rem. Benefits:
Rem. Deduct:
Ins. Company:
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?
YesNo
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?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Pregnant/Trying to get pregnant? YesNo
Taking oral contraceptives? YesNo
Nursing? YesNo
AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther
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? YesNo
Comments:
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.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
Date
Schedule an Appointment
850 South Wabash, Suite 240 Chicago, IL 60605
312-356-4700