Today’s Date:______________
Medical History Form
EMAIL:_____________________________________________________
Name _______________________________________Home Phone_________________
Address _____________________________________Bus Phone __________________
City/State/Zip Code ___________________________ Patient SS#__________________
Date of Birth __/___/_____ Sex M F Height_____Weight______Single___Married___
Name of Spouse_______________Closest Relative____________Phone ( )_________
Employer of Insured_______________________________________________________
Address_________________________________________________________________
Phone________________________ SS# of Insured______________________________
Date of Birth of Insured___________________
If you are completing this form for another person, what is your relationship to that person? ________________________________
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that at your initial visit, you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
1. Are you in good health?……………………………………………………. Yes No
2. Has there been any change in your general health within the past year?….. Yes No
3. My last physical examination was on ______________________________
4. Are you now under the care of a physician?………………………………… Yes No
If so, what is the condition being treated?___________________________
The name and address of your physician____________________________
____________________________
Have you had any serious illness, operation, or been hospitalized in the past 5 yrs. Yes No
_________________________________________________________________
If so, what medications are you taking? _________________________________
5. Do you have or have you had any of the following diseases or problems?
A. Damaged heart valves or artificial heart valves, including heart murmur or
rheumatic heart disease?………………………………………………… Yes No
1) Do you take premedication for dental treatment?…………… Yes No
B. Cardiovascular disease (heart trouble, heart attack, angina, coronary I
insufficiency, coronary occlusion, high blood pressure, arteriosclerosis,
stroke)……………………………………………………………………. Yes No
1) Do you wear a cardiac pacemaker?……………………………. Yes No
C. Allergy…………………………………………………………………… Yes No
D. Sinus trouble …………………………………………………………….. Yes No
E. Asthma or hay fever……………………………………………………… Yes No
F. Fainting spells or seizures……………………………………………….. Yes No
G. Persistent diarrhea or recent weight loss……………………………….. Yes No
H. Diabetes………………………………………………………………… Yes No
I. Hepatitis, jaundice or liver disease…………………………………….. Yes No
J. Aids or HIV infection………………………………………………….. Yes No
K. Thyroid problems……………………………………………………… Yes No
L. Respiratory problems, emphysema, bronchitis……………………….. Yes No
M. Arthritis or painful swollen joints…………………………………….. Yes No
N. Stomach ulcer or hyperacidity………………………………………… Yes No
O. Kidney Trouble……………………………………………………….. Yes No
P. Tuberculosis…………………………………………………………… Yes No
Q. Persistent cough or cough that produces blood……………………….. Yes No
R. Persistent swollen glands in neck……………………………………… Yes No
S. Low blood pressure……………………………………………………. Yes No
T. Sexually transmitted disease…………………………………………… Yes No
U. Epilepsy or other neurological disease………………………………… Yes No
V. Problems with mental health…………………………………………… Yes No
W. Cancer………………………………………………………………….. Yes No
6. Have you had abnormal bleeding?………………………………………………. Yes No
a. Have you ever required a blood transfusion?………………………….. Yes No
7. Do you have any blood disorder such as anemia?……………………………….. Yes No
8. Have you ever had any treatment for a tumor or growth?……………………….. Yes No
9. Are you allergic or have you had a reaction to:
a. Local anesthetic…………………………………………………………. Yes No
b. Penicillin or other antibiotics…………………………………………… Yes No
c. Sulfa Drugs……………………………………………………………… Yes No
d. Barbiturates, sedatives, or sleeping pills……………………………….. Yes No
e. Aspirin………………………………………………………………….. Yes No
f. Codeine or other narcotics……………………………………………… Yes No
g. Other____________________________________________________
10. Have you had any serious trouble associated with any previous dental treatment?. Yes No
11. Do you have any disease, condition or problem not listed above that you think we
should know about?……………………………………………………………….. Yes No
12. Are you wearing removable dental appliances?…………………………………… Yes No
WOMEN
13. Are you pregnant?…………………………………………………………………. Yes No
14. Are you nursing?…………………………………………………………………… Yes No
15. Are you taking birth control pills?………………………………………………… Yes No
16. Would you like to discuss the use of Nitrous Oxide during your dental treatment? Yes No
Chief Dental Complaint____________________________________________________________
____________________________________________________________________________________
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that may have been made in the completion of this form.
Patient’s signature ______________________________________________________
Dentist’s signature _____________________________________________________
Medical History Update:
_____________________________________________________________________________________
_____________________________________________________________________________________
TMJ EVALUATION FORM
Yes No
1. Do you have trouble opening your mouth? ____ ____
2. Do you experience headaches when you awake
in the morning? ____ ____
3. Do you experience earaches even though you
do not have a cold or sinus infection? ____ ____
4. Have you experienced pain or discomfort in the
back of your neck or down the right or left side
of your arm? ____ ____
5. During mastication (chewing), do you experience
any discomfort in your facial muscles? ____ ____
6. Have you been told that you grind your teeth
while you are asleep? ____ ____
7. Do you hear popping or clicking when you open
your mouth? ____ ____
8. Has your jaw ever locked open? ____ ____
9. Do you chew gum? ____ ____
10. Do you find yourself clinching your teeth when
you are driving the car? ____ ____
Name_________________________________Date___________________
OAK BROOK DENTAL AFFILIATES, PC
James B. Chidester, DDS
120 Center mall, Suite 510
Oak Brook, IL 60523
(630) 571-0393
Consent:
1. The undersigned hereby authorizes Dr. Chidester to take X-rays, study models,
photographs or any other diagnostic aids deemed appropriate by the Doctor to make a
thorough diagnosis of my dental needs.
2. I also authorize Doctor to perform all recommended treatment agreed upon by me and
to use the appropriate medication and therapy indicated for such treatment in
connection with (name of patient)________________________. I understand that
using anesthetic agents involves a certain risk. Furthermore, I authorize and consent
that Doctor choose and employ such assistance as deemed fit to provide
recommended treatment.
3. I understand that all responsibility for payment of dental services provided in
these offices for my dependents or myself is mine. Due and payable at the time
services are rendered, unless other pre-arrangements have been made. In the event
payments are not received by the agreed upon dates, I understand that a monthly
finance charge of 1 ½% may be added to my account. I further understand that dental
insurance coverage is a contract between myself and the insurance company and not
the Doctor.
4. Lastly, in the event that I fail to show up for my appointment or fail to give 24-hour
Notice of Cancellation, I agree to pay the normal charge for an office visit or a
hygiene visit. The charge for a Monday-Friday visit is $80.00 and the charge for a
Saturday visit is $160.00.
Patient Signature_______________________________________________Date_____________
INSURANCE INFORMATION
Insured Name________________________________ Date of Birth_________________
SS# of Insured___________________ Phone of Insurance Co._____________________
Name of Insurance Co._______________________ Group No._____________________
Employer of Insured_______________________________________________________
Address_________________________________________________________________
Phone No._____________________________
To All Patients Covered by Insurance PPO and HMO’S
Your insurance provides you with a discounted fee for dental procedures. The only way this arrangement can be amenable for both the provider and the recipient of the dental care is for us to receive the payment of all copayments at the time of service. Carrying a dental patient until they wish to pay makes it impossible to pay the dental office overhead and required laboratory fees necessary to complete the work. We provide the highest quality care to all of our patients, regardless of their insurance arrangements and hope that you understand the need for this arrangement in order to provide you with the level of care that you deserve.
Your cooperation with our policy is greatly appreciated.
Please sign below to acknowledge this policy:
Patient’s signature______________________________________ Date______________
{NAME OF PRACTICE}
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I, , have received a copy of this office’s Notice of
Privacy Practices.
{Please Print Name}
{Signature}
{Date}
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
¨ Individual refused to sign
¨ Communications barriers prohibited obtaining the acknowledgement
¨ An emergency situation prevented us from obtaining acknowledgement
¨ Other (Please Specify)
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).