Patient Health History

* - required information
If information not available please enter "None" or "Unknown"

Pharmacy Name
Phone

Patient
Date
* Home Phone
Work Phone
Cell/Pager
Email
* Patient Name
Address
City
State
Zip
Social Security #
Driver's Lic. #
Sex:	Male Female
Age
Birthday
Marital status:

Employer
Employed By
Occupation
Business Address
City
State
Zip
Telephone #

Spouse (only required if married)
Spouse Name
Birthday
Employed By
Business Address
City
State
Zip
Telephone #
Social Security #

Person Responsible For Account
Check to copy Patient information into fields below
Check to copy Spouse information into fields below
Name:
Relation:
Billing Address:
Home Phone #
Driver's Lic. #
Employer:
Work Phone #
Ext:
Social Security #

Dental Insurance Primary Carrier
Check if no Primary insurance
Insured's Name
ID # or Social Security #
Insurance Company
Telephone
Address
City
State
Zip
Group Number
ID Number
Birthdate
Insured's Employer

Dental Insurance Secondary Carrier
Check if no Secondary insurance
Insured's Name
ID # or Social Security #
Insurance Company
Telephone
Address
City
State
Zip
Group Number
ID Number
Birthdate
Insured's Employer



In case of emergency, who should be notified?
Telephone #
* Whom may we thank for referring you?

Medical History
Physician's Name
Address
Telephone #
Date of Last Physical


Please check the box of any condition you may have had.
A.I.D.S/ HIV Positive or Other	Heart Murmur
Allergies to Anesthetics	Heart Pacemaker
Allergy to Colored Dyes	Hemophilia
Allergy to Latex	Hepatitis, Jaundice or Liver Disease
Angina Pectoris	High Blood Pressure
Arthritis/Rheumatism	Hypoglycemia
Artifical Heart Valves	Kidney Problem
Artificial Joints	Low Blood Pressure
Aspirin Taken Daily	Mitral Valve Prolapse
Asthma	Nervous Problems
Back Problems	Premedicate
Blood Disease	Psychiatric Care
Blood Transfusion	Recent Weight Loss
Cancer, Leukemia	Respiratory Problem
Chemical Dependency	Rheumatic Fever
Chemotherapy/Radiation Therapy	Sinus Problems
Chronic Diarrhea	Special Diet
Circulatory Problems	Stroke
Contact Lenses	Swollen Neck Glands
Diabetes	Thyroid Disease
Epilepsy/Seizures	Tuberculosis
General Allergies* (List below)	Ulcer
Glaucoma	Venereal Disease
Headaches	Heart Disease or Attack
Other* (List below)

General Allergies:
Other:


Dental History
What is the reason for your visit today?
Is there anything about having dental treatment that you would like us to know?		Yes No
If yes, please describe:

Date of Last:
Dental Visit
Dental Cleaning
Full Mouth X-ray
Bitewing X-rays
What treatment was done at your last dental visit?

Previous Dentist
Previous Dentist's Name
Telephone #
Address
City
State
Zip Code


How often do you have dental examinations?
How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?		Yes No
If yes, please describe:


Check "Yes" or "No" to each item.

Do you:
Clench or grind your teeth while awake or asleep?		Yes No
Bite your lips or cheeks regularly?		Yes No
Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)?		Yes No
Mouth breathe while awake or asleep?		Yes No
Have tired jaws, especially in the morning?		Yes No
Smoke/chew tobacco?		Yes No
How much?


Have you ever had:
Orthodontic treatment?		Yes No
Oral surgery?		Yes No
Periodontal treatment?		Yes No
Your teeth ground or the bite adjusted?		Yes No
A bite plate or mouth guard?		Yes No
A serious injury to the mouth or head?		Yes No
If yes, please describe, including the cause:


Are any of your teeth sensitive to:
Hot or cold		Yes No
Sweet		Yes No
Biting or chewing		Yes No
Have you noticed any mouth odors or bad tastes?		Yes No
Do you frequently get cold sores, blisters or any other oral lesions?		Yes No
Do your gums bleed or hurt?		Yes No
Have your parents experienced gum disease or tooth loss?		Yes No
Have you noticed any loose teeth or a change in your bite?		Yes No
Do you have difficulty in chewing on either side of the mouth?		Yes No
Does food tend to become caught in between your teeth?		Yes No
If yes, where?


Have you ever experienced:
Clicking or popping of the jaw?		Yes No
Pain? (joint, ear, side of face)		Yes No
Difficulty in opening or closing the mouth?		Yes No
Headaches, neckaches or shoulder aches?		Yes No
Sore muscles (necks, shoulders)?		Yes No


Are you happy with your smile?		Yes No
Are you pleased with the color of your teeth?		Yes No
Would you like to keep all of your teeth all of your life?		Yes No
Do you feel nervous about having dental treatment?		Yes No
If yes, what is your biggest concern?
Have you ever had an upsetting dental experience?		Yes No
If yes, please describe


Do you have any drug allergies or have you ever had any adverse reaction to any medication or substance?		Yes No
If yes, list
Have you ever responded adversely to medical or dental treatment?		Yes No
Have you ever been advised to be pre-medicated prior to any dental treatment?		Yes No
Are you taking any medication at this time?		Yes No
If yes, what
Have you ever taken Phen-Fen or Redux?		Yes No
If so, have you seen a cardiologist for a consult since taking it?		Yes No
Are you under the care of a physician?		Yes No
If yes, for what condition
If Patient is a child what is his/her weight?
Have you had a recent transfusion?		Yes No
Is there anything else we should know about your medical history

Women -- Are you:

Pregnant? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

9350 Waukegan Road
Morton Grove, IL 60053
847.470.0850
nscdh@smilesforyou.com