pain free dentistry
Chicago 312-642-6631 | Western Springs 708-246-1666 | Skokie 847-329-7300

Chicago Dental Arts :: Veneers :: Crowns :: Dental Implants :: Chicago :: Skokie :: Western Springs

Patient Information Form

   

PATIENT INFORMATION

  
   
Patient's name* :
If below 18 years, Parent/Guardian's name :
Home address :
Email* :
How did you find us? :
In case of  emergency, 
contact : 
   
DOB :
City / State :
Work phone :
Spouse name :
Zip :
Cell phone :
Employer :
Phone # :
   

Health and Dental History

  
   
Physician's Name:
Phone :
Are you taking any medication now, including regular dosages of aspirin, vitamins, herbs, etc ? Yes   No
If yes, please list name and dosage :
   
Are you allergic to any medications or substances ?
Penicillin :
Latex :
Codeine :
Metals :
Sulfa :
Food or Others please list :
Have you been under the care of a medical doctor during the past two years ? Yes   No
If so, for what ?
 

Indicate which of the following you have had, or have at present
 
Rheumatic Fever Yes   No Headaches Yes   No
       
Heart Concerns Yes   No Braces Yes   No
       
Congenital Heart Disease Yes   No Jaw Pain Yes   No
       
Heart Murmur Yes   No Jaw Popping Yes   No
       
High Blood Pressure Yes   No Limited Jaw Opening Yes   No
       
Mitral Valve Prolapse Yes   No Loose Teeth Yes   No
       
Stroke Yes   No Bleeding Problems Yes   No
       
Asthma / Respiratory Disorder Yes   No Clenching Yes   No
       
Anemia / Blood Disorder Yes   No Grinding Yes   No
       
Liver Disease / Jaundice Yes   No Sensitive Teeth Yes   No
       
Tuberculosis Yes   No Difficulty Chewing Yes   No
       
Artificial Joints Yes   No Insomnia / Frequent waking Yes   No
       
Kidney Trouble Yes   No Psychiatric / Psychological Yes   No
       
Radiation / Chemotherapy Yes   No Neurological Disorders Yes   No
       
Epilepsy / Seizures Yes   No Snoring Yes   No
       
Hepatitis A B C Yes   No AIDS / HIV Yes   No
 
 
Does the thread shred when you floss ? Yes   No Do you like to improve your smile? Yes   No
       
Do food particles catch between your teeth ? Yes   No Do you feel pain in any of your teeth? Yes   No
       
Do you smoke ? Yes   No Would you be interested in preventing bad breadth? Yes   No
       
Do you use Chewing Tobacco? Yes   No Do you ever get a bad taste in your mouth? Yes   No
       
Do your gums bleed ? Yes   No Do you have any sores or lumps in or near your mouth? Yes   No
       
Does your breath concern you ? Yes   No Have you ever had any difficult extractions in the past? Yes   No
       
Have you ever worn braces? Yes   No Do you wear dentures / partials? If yes date of placement? Yes   No
       
Have you noticed any loose teeth or change in your bite? Yes   No Would you be interested in straightening your teeth without having braces? Yes   No
       
If you could easily and safely whiten your teeth, would you be interested? Yes   No    
 
 
Do you have or have had any disease, condition or problem not listed above ?
Have you ever undergone any cosmetic procedure(s) ? Yes   No
If yes please give details
Female Patients - Are you Pregnant ? Yes   No
  Nursing ? Yes   No
  Taking birth control pills ? Yes   No
 

New Patient Questionnaire
 
What are your areas of concern?
In your opinion, what is the status of your oral health at this time?
Do you have any family friends who already come to our office?

What do you already know about our office and what are your expectations?
How healthy do you want your oral health to be?

Average
What quality of dentistry do you want us to recommend?
If you had a magic wand, what might you change, if anything, about your smile?
Has fear ever been an issue for you in a dental office?
Yes   No
Why did you leave your last dental office?
Has time ever been a factor in getting your dental work done?
Yes   No
Has the cost of dental treatment been a concern for you?
Yes   No
Is there any additional information you would like us to know?
   
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 or agency, which may release such information to you. I will notify the doctor of any change in my health or medication.Consent for treatment I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my and/or my child's dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and employ such assistance as required providing proper care. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
   
Patient Signature : Date :