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Patient Information

Your Name *

Date *

Social Security *

Date of Birth *

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Email *

Marital Status *

Dental Insurance *

Employer of Insured *

Name of Insured *

Insured Date of Birth *

Insured Social Security/Member ID *

Emergency Contact *

Whom may we thank for referring you? *

Medical History

General Questions

Yes — No — If, yes please write

Are you under a physician’s care now? *

Have you had any serious illness, operations or have been hospitalized in the last 5 years? *

Have you ever had a serious head or neck injury? *

Are you taking any medications, pills, or drugs? *

Do you take, or have you taken, Fen-Phen or Redux? *

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates? *

Are you on a special diet? *

Do you use tobacco? *

Do you use or have you used in the past alcohol or other substances? *

Women: Are you…
Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

Are you allergic to any of the following? *
AsprinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsNo allergiesOther

Current Health

Do you have, or have you had, any of the following? *
AIDS/HIV PositiveRadiation TreatmentDiabetesHepatitis ARecent Weight LossDrug AddictionHepatitis B or CRenal DialysisAnemiaRheumatic FeverEmphysemaHigh Blood PressureRheumatismArthritis/GoutEpilepsy or SeizuresHigh CholesterolScarlet FeverArtificial Heart ValveExcessive BleedingHives or RashArtificial JointExcessive ThirstHypoglycemiaSickle Cell AnemiaAsthmaFainting Spells/DizzinessIrregular HeartbeatSinus TroubleBlood DiseaseKidney ProblemsLeukemiaStomach/Intestinal DiseaseBreathing ProblemsFrequent HeadachesLiver DiseaseStrokeBruise EasilyLow Blood PressureSwelling of LimbsCancerThyroid DiseaseChemotherapyHay FeverMitral Valve ProlapseChest PainsHeart Attack/FailureOsteoporosisTuberculosisHeart MurmurPain in Jaw JointsTumors or GrowthsHeart PacemakerUlcersConvulsionsVenereal DiseaseAutoimmune DiseasesDepressionBleeding GumsHistory of OrthoCanker Sores

Have you ever had any serious illness not listed? *

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© 2019. Major Dental Clinics. All rights reserved.

Milwaukee

788 N Jefferson Suite 880 Milwaukee, WI 53202
(414) 276-4262
M-Thur 8-5, Closed Fri and Closed Sat

Chicago

1030 W Higgins Suite 260 Park Ridge, IL 60068
(773) 777-1111
Monday - Friday 9-6

Phones:Chicago (773) 777-1100; Milwaukee (414) 276-4262

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© 2021. Major Dental Clinics. All rights reserved.