Medical History Form Online Patient Medical History Kevin J. Quinn DDS 121 E Liberty St. Suite 1 Wauconda IL 60084 Phone: 1-847-526-7383 Fax: 1-847-526-7385 Patient Information First Name: * Last Name: * Birth Date: * Gender: —Please choose an option—MF Email Address: Address 1: Pref. Phone: * HomeWorkCell Address 2: Home Phone: City: Work Phone: State: IL-IllinoisOther State Cell Phone: Zip: Check here to keep your personal information on this computer. Your information will only be applied on MOGO's Online Forms for future use. Dental Questions Medical Questions Allergies Medical History (Part 1) Medical History (Part 2) How long since you have seen a dentist? 1 year2 years3 years4 years5+ years Date of last complete dental exam: Date of last full mouth x-rays: Are you having problems now? YesNo If Yes: Is your present dental health good? YesNo Do you wear dentures? NoYes - PartialYes - Full Are you unhappy with your dentures? YesNo Would you like permanent replacements? YesNo Are you apprehensive about dental treatment? YesNo Name of Previous Dentist: Previous Dentist City & State: Please rank the following in the order in which they would KEEP YOU FROM having dental treatment: (with "1" being least likely to keep you from having treatment and "5" being very likely) Fear of Pain: 12345 Cost of Treatment: 12345 Lack of Concern: 12345 Missing Work Time: 12345 Have you had any periodontal (gum) treatments? YesNo Do your gums bleed or feel tender or irritated? YesNo Are your teeth sensitive to hot, cold, or pressure? YesNo Are you unhappy with the appearance of your teeth? YesNo Are you aware of grinding or clenching your teeth? YesNo Do you have headaches, ear aches, or neck pains? YesNo Have you worn braces on your teeth (orthodontics)? YesNo Do you have discolored teeth that bother you? YesNo Would you like your smile to look better or different? YesNo Do you regularly use dental floss? YesNo Do you have any current health problems? YesNo Are you currently under a physician's care? YesNo If Yes: Have you ever been hospitalized? YesNo Have you ever had major surgery? YesNo If Yes: Are you currently taking any medications? YesNo If Yes, please list below: Have you ever taken Fen-Phen/Redux? YesNo Are you on a special diet? YesNo Are you pregnant? YesNo Do you use tobacco? YesNo Do you use controlled substances? YesNo Are you allergic to or have you reacted adversely to any of the following medications? AspirinPenicillinNitrous OxideLocal AnestheticCodeineLatex GlovesErythromycin Are you aware of being allergic to any other medications or substances? YesNo If Yes, please list below: Is there any other Medical or Dental information that you feel we should know about? Family Physician: Physician Phone: Physician Email: Check [No] for all Please mark Yes or NO for each of the following which you have had or currently have: AIDS/HIV positive YesNo Alzheimers Disease YesNo Anaphylaxis YesNo Angina YesNo Arthritis YesNo Artificial Joint YesNo Artificial Heart Valve YesNo Asthma YesNo Blood Disease YesNo Blood Transfusion YesNo Breathing Problems YesNo Bruise Easily YesNo Cancer YesNo Chemotherapy YesNo Chest Pains YesNo Cold Sores/Fever Blisters YesNo Congenital Heart Disorder YesNo Convulsions YesNo Cortisone Medicine YesNo Diabetes YesNo Drug Addiction YesNo Emphysema YesNo Epilepsy or Seizures YesNo Excessive Bleeding YesNo Excessive Thirst YesNo Fainting Spells/Dizziness YesNo Frequent Cough YesNo Frequent Diarrhea YesNo Frequent Headaches YesNo Genital Herpes YesNo Glaucoma YesNo Gout YesNo Hay Fever YesNo Heart Attack/Failure YesNo Heart Murmur YesNo Heart Pacemaker YesNo Heart Trouble/Disease YesNo Check [No] for all Please mark Yes or NO for each of the following which you have had or currently have: Hemophilia YesNo Hepatitis A YesNo Hepatitis B or C YesNo High Blood Pressure YesNo Hives or Rash YesNo Hypoglycemia YesNo Irregular Heartbeat YesNo Kidney Problems YesNo Leukemia YesNo Liver Disease YesNo Low Blood Pressure YesNo Lung Disease YesNo Mitral Valve Prolapse YesNo Pain in Jaw Joints YesNo Parathyroid Disease YesNo Psychiatric Care YesNo Radiation Treatments YesNo Recent Weight Loss YesNo Renal Dialysis YesNo Rheumatic Fever YesNo Rheumatism YesNo Shingles YesNo Sickle Cell Disease YesNo Sinus Trouble YesNo Spina Bifida YesNo Stomach Disease YesNo Stroke YesNo Swelling of Limbs YesNo Thyroid Disease YesNo Tonsillitis YesNo Tuberculosis YesNo Tumors or Growths YesNo Ulcers YesNo Venereal Disease YesNo Yellow Jaundice YesNo Start Over <- Previous Next ->
