Online Registration

Online

Medical History Form

Jeffrey J. Gentile

1220 Roosevelt Road

Glen Ellyn IL 60137

Phone: 1-630-953-1700 Fax: 1-630-953-0130

Patient Information

First Name:*

Last Name:*

Birth Date:

Gender:

Email Address:

Address 1:

Pref. Phone:

Home

Work

Cell

Address 2:

Home Phone:

City:

Work Phone:

State:

Cell Phone:

Zip:

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Medical History
Medical History

Check [No] for all

Have you ever had Covid-19

Yes

Vaccination for Covid-19

Yes

Do you have any current health problems?

Yes

Are you currently under a physician's care?

Yes

If Yes:

Are you currently taking any medications?

Yes

If Yes, please list below:

**some medications used in the dental office can decrease the effectiveness of birth control pills

Have you ever been hospitalized?

Yes

Have you ever had major surgery?

Yes

If Yes:

Have you ever taken Fen-Phen/Redux?

Yes

Do you take Ginko Biloba?

Yes

Are you on a special diet?

Yes

Are you pregnant?

Yes

Do you use tobacco?

Yes

Do you Vape?

Yes

Previously

* Routine exam of oral tissues is essential in early oral cancer detection or smoking associated periodontal disease

Do you use controlled substances?

Yes

*some drugs and medications used in routine dental care are not compatible with several illegal drugs. The combination can be dangerous to your health.

Are you allergic to or have you reacted adversely to any of the following medications?

Aspirin

Penicillin

Nitrous Oxide

Local Anesthetic

Codeine

Latex Gloves

Erythromycin

Are you aware of being allergic to any other medications or substances?

Yes

If Yes, please list below:

Do you have any Food Allergies?

Yes

If Yes,

Dairy

Peanut

Tree Nuts

Other:

Is there any other Medical or Dental information that you feel we should know about?

Family Physician:

Physician Phone:

Physician Email:

Please mark Yes or NO for each of the following which you have had or currently have:

Acid Reflux (GERD)

Yes

AIDS/HIV positive:

Yes

Alzheimers Disease:

Yes

Anaphylaxis:

Yes

Angina:

Yes

Arthritis:

Yes

Anorexia

Yes

Artificial Joint:

Yes

Artificial Heart Valve:

Yes

Asthma:

Yes

Blood Disease:

Yes

Blood Transfusion:

Yes

Breathing Problems:

Yes

Bruise Easily:

Yes

Bulimia

Yes

Cancer:

Yes

Chemotherapy:

Yes

Radiation Treatments?

Yes

Chest Pains:

Yes

Cold Sores/Fever Blisters:

Yes

Congenital Heart Disorder:

Yes

Convulsions:

Yes

Cortisone Medicine:

Yes

Diabetes:

Yes

Insulin Dependant?

Yes

Drug Addiction:

Yes

Emphysema:

Yes

Epilepsy or Seizures:

Yes

Excessive Bleeding:

Yes

Excessive Thirst:

Yes

Fainting Spells/Dizziness:

Yes

Frequent Cough:

Yes

Frequent Diarrhea:

Yes

Frequent Headaches:

Yes

Genital Herpes:

Yes

Glaucoma:

Yes

Gout:

Yes

Hay Fever:

Yes

Heart Attack/Failure:

Yes

Heart Murmur:

Yes

Heart Pacemaker:

Yes

Heart Trouble/Disease:

Yes

Please mark Yes or NO for each of the following which you have had or currently have:

Hemophilia:

Yes

Hepatitis A:

Yes

Hepatitis B or C:

Yes

High Blood Pressure:

Yes

Hives or Rash:

Yes

Hypoglycemia:

Yes

Irregular Heartbeat:

Yes

Kidney Problems:

Yes

Leukemia:

Yes

Liver Disease:

Yes

Low Blood Pressure:

Yes

Lung Disease:

Yes

Mitral Valve Prolapse:

Yes

Pain in Jaw Joints:

Yes

Parathyroid Disease:

Yes

Psychiatric Care:

Yes

Radiation Treatments:

Yes

Recent Weight Loss:

Yes

Renal Dialysis:

Yes

Rheumatic Fever:

Yes

Rheumatism:

Yes

Shingles:

Yes

Sickle Cell Disease:

Yes

Sinus Trouble:

Yes

Spina Bifida:

Yes

Stomach Disease:

Yes

Stroke:

Yes

Swelling of Limbs:

Yes

Thyroid Disease:

Yes

Tonsillitis:

Yes

Tuberculosis:

Yes

Tumors or Growths:

Yes

Ulcers:

Yes

Venereal Disease:

Yes

Yellow Jaundice:

Yes