Medical History E-Form - Advanced Cosmetic Dentistry

Medical Health History E-Form

Please take a few minutes to fill out this form as complete as you can. Some sections must be completed in the office so you may not be able to fill them out online. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
Welcome

All information provided is completely confidential.
Patient Name

First Name Last Name
Date of Birth

/ Month / Day Year

For Women Only

	Yes	No	N/A
Birth Control
Pregnant? If yes, what trimester? _________
Nursing

Please provide the dates for your last medical exam:
Primary Care Physician

First Name Last Name

Physician Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Physician Phone Number

- Area Code Phone Number

	Yes	No
Within the past year, have there been any changes in your general health?
Have you ever had complications following dental treatment?
Are you currently under the care of a physician due to a specific condition?
Have you ever been hospitalized within the last 15 years due to a surgery or illness?

If any of the previous questions are marked "yes", please explain:
Please list any medications, drugs, pills or herbal remedies, including aspirin you currently take:
Have you ever taken any group of drugs for weight loss collectively referred to as Fen-Phen? These include combinations of: Lonimin, Adipex, Fastin (Brand Names of Phentermine), Pondimin (Fenfluramine) and Redux,

Yes No
Have you ever used a bisphosphonate medication for Osteoporosis common brand names: Fosamax, Actonel Atelvia, Didronel, Boniva:

Yes No
Allergies (Check All That Apply)

Aspirin Latex Codeine Penicillin Erythromycin Sulfa Hay Fever Asthma

	Yes	No
Respiratory Problems
Tuberculosis
Emphysema
Shortness of Breath
Pneumocystitis
Tonsillitis
Swollen Adenoids
Heart Disease
Heart Attack
Stroke
High Blood Pressure
Low Blood Pressure
Heart Surgery
Chest Pain
Take Blood Thinners
Heart Murmur
Mitral Valve Prolapse
Artificial Heart Valve
Pacemaker
Used: Fen-Phen/Redux
Congenital Heart Defect
Rheumatic Fever
Scarlet Fever

	Yes	No
Dizziness
Fainting
Frequent Vomiting
Frequent Headaches
Back Problems
Cortisone Treatments
Stomach Problems
Ulcers
Blood Disease
Leukemia
Anemia
Hemophilia
Excessive Bleeding
Bruise Easily
Daily Aspirin Therapy
Sickle Cell Disease
Blood Transfusion
Artificial Joints
Any Artificial Implant

Does your surgeon or treating physician recommend Pre-Med for Dental procedures?

Yes No

	Yes	No
Cosmetic Surgery
Head Injuries
Sinus Problems
Chronic Headaches
Pain In Ear
Arthiritis/Rheumatism
Rheumatic Fever
Herpes
Shingles
AIDS/HIV
Hepatitis A
Hepatitis B
Venereal Disease
Mental Disorders
Nervous Disorders
Received Psychological Care
Take Antidepressants
Smoker
Chewing Tobacco
Substance Abuse

	Yes	No
Kidney Disease
Thyroid Problems
Liver Disease/ Jaundice
Hypoglycemia
Diabetes
Slow wound healing
Tumors
Cancers
Chemotherapy
Radiation Treatment
Epilepsy or Seizures
Glaucoma
Contact Lenses
Reaction to Dental Anesthetic
Osteoporosis
Osteomalacia (Rickets)
Vitamin D Deficient
Taken Fosamax

Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
This Section MUST be signed in the office

To the best of my knowledge all of the preceding information is true and accurate.

Signature: _________________________________

Date: ________________
Summary
Check Off Items Below To Indicate The E-Forms You Filled Out On Our Website:

Patient Personal Information Form (Faxed to: 312 263-7013) Dental Insurance E-Form (Faxed to: 312 263-7013) Dental Health History E-Form Cosmetic Questionnaire E-Form Cyber Consult *Send X-Rays & Images Personal Preferences Patient Communication E-Form Pain Management Patient Communication E-Form Bad Dental Experience Patient Communication E-Form Patient Satisfaction Survey E-Form
We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.

If you are a New Patient

You can fill out your new patient paper work now

1. Patient Personal Information Form (Print, Fill Out & Fax or Email)

2. Dental Insurance Information (Print, Fill Out & Fax or Email)

3. Dental History E-Form

If you have had a Bad Dental Experience, we strongly recommend you review

Bad Dental Experience Patient communication E-form

Recommended Reading:

1. Relaxation Techniques To Stay Calm During Dental Treatments

2. Self Help Strategies to overcome Dental Pain & Fear

3. Top 25 Dental Fears & Our Solutions “Facing Your Fears”

For Those Seeking Exceptional Care, please fill out:

Personal Preferences Patient Communication E-Form

For Those Seeking Cosmetic treatment its “Very important” that you fill out:

Cosmetic Questionnaire

What Happens Next

It’s required that we keep your online information private and secure. Accordingly you will need to create and enter a 4-6 digit ID number on any E-form filled out on our site. Retain this 4-6-digit number as you will need to provide it to our scheduling coordinator. In turn, they will download your online information and save it to a new account hosted on our private secure server.

Your best option is to call our office in advance of your appointment date. This will allow extra time for Dr Landers to review the E-forms you took your time to fill out.

When you Call Please provide the Following E-form Information:

1. First & Last Name

2. The Names of E-Forms You Fill Out Online

3. The 4-6 Digit Number You Entered On The E-Forms.

We Will Use This ID Number To Attach Your E-Forms “Privately” To Your New Account At Our Office

Contact Us Today! 312-263-7823
To keep your information private and secure, please enter a 4-6 digit ID number of your choice below. Retain this 4-6 digit ID number as you will need to provide our office staff with that number during your appointment so we may retrieve your submission. You may also call our office beforehand and provide us with that number. *
Copyright Statement

Advanced Cosmetic & Implant Dentistry, has exclusive rights under U.S. and foreign copyright laws. Unless otherwise indicated, all materials on these pages are copyrighted by the Advanced Cosmetic & Implant Dentistry inc. All rights reserved. No part of these pages, either text or image may be used for any purpose other than personal use. Therefore, reproduction, modification, storage in a retrieval system or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for reasons other than personal use, is strictly prohibited without prior written permission.

© Advanced Cosmetic & Implant Dentistry
ChicagosCosmeticDentist.com
312-263-7823
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Medical Health History E-Form

Welcome

Summary