Dentistsofhinsdalelake.com

HEALTH INFORMATION & HISTORY
Patient’s Name__________________________________________________ Date_ ______________________________
Address____________________________________City_ _________________ State__________ Zip__________________ Occupation_ _______________________________SSN_#_ _______________ Date_of_Birth_ ______________________ Height_______ Weight________ Single______ _ Married_____ _ Name_of_Spouse____________________________ Phone_Number_-_Home_____________________Work_________________ Cell________________________________ Employer__________________________ Insurance_ID_________________ Group_#____________________________ Referred_by_______________________________________ E-mail_ ___________________________________________ *If you are completing this form for another person
Your_Name_________________________________Phone_______________________ Relationship_ _______________ *Emergency contact (if not listed above)
Name______________________________________Phone_______________________ Relationship_ _______________ Primary_Physician__________________________Phone_______________________ City___________ State_________ Within the last 3 years have you been hospitalized or had surgery?_
If_yes,_please_give_reasons_and_dates_ __________________________________________________________________ Have you ever been instructed to take any medications or take any special precautions before any
dental appointment?_
If_yes,_please_explain__________________________________________________________________________________ Are you taking any drugs, medications or treatments at this time?__
Please_list_prescribed,_over_the_counter_and_supplements________________________________________________ _____________________________________________________________________________________________________ Are you having or have you had radiation or chemotherapy treatment?__ yes_ _
If_yes,_for_how_long?__________________________________________________________________________________ Dentists of Hinsdale Lake • 6300 Kingery Highway • Suite 216 • Willowbrook, Illinois • 60527 • 630.323.5333 Are you allergic to or have you ever experienced an unusual reaction to:
Are you allergic to or have you ever had any reaction to any of the following drugs:
Have you had an allergic reaction or an unusual response to ANY other medications,
drugs, pills or treatments?_
If_yes,_please_list____________________________________________________________________________ Are you taking now or have you ever taken orally administered bisphosphonates such as
Actonel, Boniva, Fosamax, Skelid, or Didronel?__
Have you ever had intravenously administered bisphosophonates such as Aredia,
Zometa, or Bonefos? _
Do you have or have you ever had any of the following? (Please check any that apply)
_ Hepatitis,_jaundice,_or_other_liver_problems _ Tuberculosis,_emphysema,_or_lung__disorder _ Ulcers,_acid_reflux_or_stomach_problems _ A_sore_or_wound_that_bleeds_easily_or_does__ If_yes,_type_and_date________________________ _ An_active_sexually_transmitted_disease_(STD) _ If_yes,_date_________________________________ _ Treatment_for_any_psychiatric_condition _ Excessive_bleeding_from_any_cut_or_incident _ Rheumatic_heart_disease/_rheumatic_fever *Women only
_ Any_artifical_joint,_joint_surgery,_or_prosthesis _ Heart_valve_damage_/_Mitral_valve_prolapse _ If_yes,_what_joint_or_area____________________ _ If_yes,_what_is_your_due_date?________________ When_was_the_surgery_done?________________ _ If_yes,_what_type____________________________ _ Are_you_using_birth_control_medication? _ If_yes,_what_type____________________________ Dentists of Hinsdale Lake • 6300 Kingery Highway • Suite 216 • Willowbrook, Illinois • 60527 • 630.323.5333 Do you have any other diseases, conditions, or medical problems, or is there any other
information that you would like us to know about, or that we should be made aware of?
If_so,_please_explain___________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Consent_—_To the best of my knowledge, all of the preceding information is correct and if there is ever
any change in health, or medications, this practice will be informed. I also consent to allow this practice to contact any healthcare providers and to have the patients healthcare information released to aid in care and treatment. I also, hereby consent to allow diagnosis, proper healthcare and treatment to be performed by this practice for the above named individual until further notice. I understand there are no guarantees or warranties in health or dental care. Signature_Date_______________________________________________________________________________ Reviewed_by_ ________________________________________________________________________________ DENTAL & ORAL HEALTH INFORMATION
Patient’s name_____________________________________________________ Date_____________________
Please_describe_any_specific_dental_problem_or_discomfort_you_are_having_at_this_time_____________ How_long?_ __________________________________________________________________________________ If you’ve had any of the following care, please list the dentists and the approximate dates.
Periodontal (gum) treatment or surgery ______________________________________________________ Braces or any type of orthodontic treatment __________________________________________________ Dental implants _____________________________________________________________________________ Any other type of oral surgery_ _______________________________________________________________ Do you have, have you had, or have you noticed any of the following signs and symptoms in your
head, neck, or mouth?
Dentists of Hinsdale Lake • 6300 Kingery Highway • Suite 216 • Willowbrook, Illinois • 60527 • 630.323.5333 __ Teeth_that_are_sensitive_to_hot,_cold_,_sweets__ __ Do_you_avoid_any_area_when_brushing_or__ _ __ An_unpleasant_taste_or_persistent_bad_breath __ Changes_in_the_way_your_teeth_fit_together __ A_clicking,_snapping_or_difficulty_when__ _ __ A_color_change_of_the_tissues_in_your_mouth __ Pain,_tenderness,_numbness_or_earaches __ Red,_swollen,_tender,_bleeding,_or_sore_gums __ Difficulty_opening_or_moving_your_jaws __ Gums_that_have_pulled_away_from_the_teeth __ Sores,_ulcers_or_rough_spots_in_your_mouth __ Difficulty_moving_your_tongue_or_“tongue_ How do you rate your overall dental health?
How_many_times_a_day_do_you_brush_your_teeth?________________________________________________ How_many_times_a_week_do_you_floss_your_teeth?_______________________________________________ Do you have any missing teeth that have not been replaced?
If_so,_why_have_they_not_been_replaced?________________________________________________________ Do you wear any removable dental appliances ?
If_yes,_what_type_and_for_how_long?____________________________________________________________ Have you ever had your teeth whitened or bleached?_
Would_you_like_your_teeth_whitened?__________________________________________________________ How do you feel about the appearance of your smile? What would you change?____________
_____________________________________________________________________________________________ Have you ever had complications from dental treatment?
If_yes,_please_explain__________________________________________________________________________ Have you ever had any other dental conditions, major trauma or injury to your head,
neck or mouth?
If_yes,_please_specify__________________________________________________________________________ *If you are a new patient to this practice
Date_of_last_dental_visit________________________________________________________________________ Dentists_name_City_and_State__________________________________________________________________ Dentists of Hinsdale Lake • 6300 Kingery Highway • Suite 216 • Willowbrook, Illinois • 60527 • 630.323.5333

Source: http://www.dentistsofhinsdalelake.com/wp-content/uploads/DOHL_Health_Form.pdf