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Medical History Form
Family Care Dental Group, Ltd.
3143 W. Devon
Chicago IL
Phone: 773-465-2922 Fax:
Patient Information
First Name:
*
Last Name:
*
Birth Date:
December 2025
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Gender:
Email Address:
Address 1:
Pref. Phone:
Home
Work
Cell
Address 2:
Home Phone:
City:
Work Phone:
State:
Cell Phone:
Zip:
Check here to keep your personal information on this computer. Your information will only be applied on MOGO's Online Forms for future use.
Dental Questions
Dental Questions
Medical Questions
Medical Questions
Allergies
Allergies
Medical History (Part 1)
Medical History (Part 1)
Medical History (Part 2)
Medical History (Part 2)
How long since you have seen a dentist?
1 year
2 years
3 years
4 years
5+ years
Date of last complete dental exam:
December 2025
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Date of last full mouth x-rays:
December 2025
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Are you having problems now?
Yes
No
If Yes:
Do you wear dentures?
No
Yes - Partial
Yes - Full
Have you had any periodontal (gum) treatments?
Yes
No
Do your gums bleed or feel tender or irritated?
Yes
No
Are your teeth sensitive to hot, cold, or pressure?
Yes
No
Are you aware of grinding or clenching your teeth?
Yes
No
Have you worn braces on your teeth (orthodontics)?
Yes
No
Do you regularly use dental floss?
Yes
No
Next ->
Do you have any current health problems?
Yes
No
Are you currently under a physician's care?
Yes
No
If Yes:
Have you ever had major surgery?
Yes
No
If Yes:
Are you currently taking any medications?
Yes
No
If Yes, please list below:
Are you pregnant?
Yes
No
Do you use tobacco?
Yes
No
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Next ->
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
No
If Yes, please list below:
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Next ->
Check [No] for all
Please mark Yes or NO for each of the following which you have had or currently have:
AIDS/HIV positive:
Yes
No
Alzheimers Disease:
Yes
No
Anaphylaxis:
Yes
No
Angina:
Yes
No
Arthritis:
Yes
No
Artificial Joint:
Yes
No
Artificial Heart Valve:
Yes
No
Asthma:
Yes
No
Blood Disease:
Yes
No
Blood Transfusion:
Yes
No
Breathing Problems:
Yes
No
Cancer:
Yes
No
Chemotherapy:
Yes
No
Chest Pains:
Yes
No
Cold Sores/Fever Blisters:
Yes
No
Congenital Heart Disorder:
Yes
No
Convulsions:
Yes
No
Cortisone Medicine:
Yes
No
Diabetes:
Yes
No
Drug Addiction:
Yes
No
Emphysema:
Yes
No
Epilepsy or Seizures:
Yes
No
Excessive Bleeding:
Yes
No
Excessive Thirst:
Yes
No
Fainting Spells/Dizziness:
Yes
No
Frequent Headaches:
Yes
No
Glaucoma:
Yes
No
Gout:
Yes
No
Hay Fever:
Yes
No
Heart Attack/Failure:
Yes
No
Heart Murmur:
Yes
No
Heart Pacemaker:
Yes
No
Heart Trouble/Disease:
Yes
No
<- Previous
Next ->
Check [No] for all
Please mark Yes or NO for each of the following which you have had or currently have:
Hemophilia:
Yes
No
Hepatitis A:
Yes
No
Hepatitis B or C:
Yes
No
High Blood Pressure:
Yes
No
Hives or Rash:
Yes
No
Hypoglycemia:
Yes
No
Irregular Heartbeat:
Yes
No
Kidney Problems:
Yes
No
Leukemia:
Yes
No
Liver Disease:
Yes
No
Low Blood Pressure:
Yes
No
Lung Disease:
Yes
No
Mitral Valve Prolapse:
Yes
No
Pain in Jaw Joints:
Yes
No
Parathyroid Disease:
Yes
No
Psychiatric Care:
Yes
No
Radiation Treatments:
Yes
No
Recent Weight Loss:
Yes
No
Renal Dialysis:
Yes
No
Rheumatic Fever:
Yes
No
Rheumatism:
Yes
No
Shingles:
Yes
No
Sickle Cell Disease:
Yes
No
Sinus Trouble:
Yes
No
Spina Bifida:
Yes
No
Stomach Disease:
Yes
No
Stroke:
Yes
No
Thyroid Disease:
Yes
No
Tonsillitis:
Yes
No
Tuberculosis:
Yes
No
Tumors or Growths:
Yes
No
Ulcers:
Yes
No
Venereal Disease:
Yes
No
<- Previous
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Medical History
