Medical History

Online

Medical History Form

Ralph Shepstone, D.D.S.

3633 W. Lake Ave., Suite 304

Glenview IL 60025

Phone: 847-998-8989 Fax:

Patient Information

First Name:*

Last Name:*

Birth Date:

The date must be less than or equal to 04/28/2025

Gender:

Email Address:

Address 1:

Pref. Phone:

Home

Work

Cell

Address 2:

Home Phone:

City:

Work Phone:

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.

Medical History
Medical History

Check [No] for all

Reason for visit

Is your present dental health good?

Yes

Are you currently have a dental problem?

Yes

If Yes, please explain:

How long since you have seen a dentist?

1 year

2 years

3 years

4 years

5+ years

When was your last complete dental exam?

When was your last full set of x-rays?

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:

Cost of Treatment:

Lack of Concern:

Missing Work Time:

How many times do you brush your teeth in a day?

Do you regularly use dental floss?

Yes

Do your gums bleed or feel tender or irritated?

Yes

Are your teeth sensitive to hot, cold, or pressure?

Yes

Have you notice any loosening of your teeth?

Yes

Does food tend to get caught between your teeth?

Yes

Do you have any lumps or sores in or near your mouth?

Yes

Have you ever had any problems with your jaw?

Yes

Have you had any head, neck, or jaw injuries?

Yes

Do you have headaches, ear aches, or neck pains?

Yes

Are you aware of grinding or clenching your teeth?

Yes

Have you had orthodontic treatment (braces)?

Yes

Have you had periodontal treatment (gum)?

Yes

Have you had oral surgery?

Yes

Do you wear either full or partial dentures?

Yes

Have you worn a bite plate, nightguard, or other appliance?

Yes

Would you like your smile to look better or different?

Yes

If Yes, please explain:

Have you ever had an upsetting experience inthe dental office?

Yes

Is there anything about having dental treatment that bothers you?

Yes

If Yes, please explain:

Do you have any current health problems?

Yes

Are you currently under a physician's care?

Yes

If Yes:

Family Physician:

Physician Phone:

Have you ever been hospitalized?

Yes

Have you ever had major surgery?

Yes

If Yes:

Are you currently taking any medications?

Yes

If Yes, please list below:

Have you ever taken Fen-Phen/Redux?

Yes

Are you pregnant?

Yes

Are you nursing?

Yes

Are you taking birth control pills?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Yes

Are you allergic to or have you reacted adversely to any of the following medications?

Aspirin

Penicillin

Nitrous Oxide

Local Anesthetic

Codeine

Latex Gloves

Erythromycin

Are you aware of being allergic to any other medications or substances?

Yes

If Yes, please list below:

Is there any other Medical or Dental information that you feel we should know about?

Please mark Yes or NO for each of the following which you have had or currently have:

AIDS/HIV positive:

Yes

Anaphylaxis:

Yes

Angina or chest pain?

Yes

Arthritis:

Yes

Artificial Joint:

Yes

Artificial Heart Valve:

Yes

Asthma:

Yes

Blood Disease:

Yes

Blood Transfusion:

Yes

Breathing Problems:

Yes

Bruise Easily:

Yes

Cancer:

Yes

Chemotherapy:

Yes

Cold Sores/Fever Blisters:

Yes

Congenital Heart Disorder:

Yes

Cortisone Medicine:

Yes

Diabetes:

Yes

Drug Addiction:

Yes

Epilepsy or Seizures:

Yes

Excessive Bleeding:

Yes

Excessive Thirst:

Yes

Fainting Spells/Dizziness:

Yes

Frequent Cough:

Yes

Frequent Headaches:

Yes

Glaucoma:

Yes

Hay Fever:

Yes

Heart Attack/Failure:

Yes

Heart Murmur:

Yes

Heart Pacemaker:

Yes

Heart Trouble/Disease:

Yes

Please mark Yes or NO for each of the following which you have had or currently have:

Hepatitis, jaundice, or liver disease?

Yes

High Blood Pressure:

Yes

Hives or Rash:

Yes

Irregular Heartbeat:

Yes

Kidney Problems:

Yes

Leukemia:

Yes

Liver Disease:

Yes

Low Blood Pressure:

Yes

Lung or breathing problems?

Yes

Psychiatric Care:

Yes

Radiation Treatments:

Yes

Recent Weight Loss:

Yes

Rheumatic Fever:

Yes

Rheumatism:

Yes

Shingles:

Yes

Sinus Trouble:

Yes

Stomach Disease:

Yes

Stroke:

Yes

Swelling of Limbs:

Yes

Thyroid Disease:

Yes

Tuberculosis:

Yes

Tumors or Growths:

Yes

Ulcers:

Yes

Venereal Disease:

Yes