Online Registration

Online

Medical History Form

North Branch Dental Works

2740 W. Foster Ave Suite 203

Chicago IL 60625-3525

Phone: 1-773-561-3368 Fax: 1-773-293-8968

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:

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:

Date of last full mouth x-rays:

Are you having problems now?

Yes

If Yes:

Is your present dental health good?

Yes

Do you wear dentures?

Yes - Partial

Yes - Full

Are you unhappy with your dentures?

Yes

Would you like permanent replacements?

Yes

Are you apprehensive about dental treatment?

Yes

Name of Previous Dentist:

Previous Dentist City & State:

Please rank the following in the order in which they would KEEP YOU FROM having dental treatment: (with "1" being least likely to keep you from having treatment and "5" being very likely)

Fear of Pain:

Cost of Treatment:

Lack of Concern:

Missing Work Time:

Have you had any periodontal (gum) treatments?

Yes

Do your gums bleed or feel tender or irritated?

Yes

Are your teeth sensitive to hot, cold, or pressure?

Yes

Are you unhappy with the appearance of your teeth?

Yes

Are you aware of grinding or clenching your teeth?

Yes

Do you have headaches, ear aches, or neck pains?

Yes

Have you worn braces on your teeth (orthodontics)?

Yes

Do you have discolored teeth that bother you?

Yes

Would you like your smile to look better or different?

Yes

Do you regularly use dental floss?

Yes

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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

Alzheimers Disease:

Yes

Anaphylaxis:

Yes

Angina:

Yes

Arthritis:

Yes

Artificial Joint:

Yes

Artificial Heart Valve:

Yes

Asthma:

Yes

Blood Disease:

Yes

Blood Transfusion:

Yes

Breathing Problems:

Yes

Bruise Easily:

Yes

Cancer:

Yes

Chemotherapy:

Yes

Chest Pains:

Yes

Cold Sores/Fever Blisters:

Yes

Congenital Heart Disorder:

Yes

Convulsions:

Yes

Cortisone Medicine:

Yes

Diabetes:

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

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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:

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

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