Online Registration

Online

Medical History Form

Dhiraj Sharma

5342 S. Archer Ave

Chicago IL 60632

Phone: 1-773-284-1645 Fax:

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

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

Is your present dental health good?

Yes

Do you wear dentures?

Yes - Partial

Yes - Full

Would you like permanent replacements?

Yes

Are you apprehensive about dental treatment?

Yes

Do you like your Smile

Yes

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

Do you have any current health problems?

Yes

Are you currently under a physician's care?

Yes

If Yes:

Have you ever been hospitalized?

Yes

Have you ever had major surgery?

Yes

If Yes:

Are you currently taking any medications?

Yes

If Yes, please list below:

Have you ever taken Fen-Phen/Redux?

Yes

Are you on a special diet?

Yes

Are you pregnant?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Yes

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:

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:

ADD/ADHD

Yes

Autism

Yes

Developmental Delay

Yes

Sensory Concern

Yes

Speech Problem, Speech Delayed

Yes

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

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