Wheeling, IL Dentist | Dental Limited

Dental Limited
Family Dentistry
Dr. Robert G. Crane
47 West Dundee Road
Wheeling, IL 60090-4866
Tel:(847) 537-7878
dentalltd@aol.com

"Something Different, Something Better."

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Registration

Patient's Name:

Date of birth:

MaleFemale

If Child: Parent's Name:
How do you wish to be addressed:
Address:
City:State:Zip:
Business Address:
Ph: Res:	Bus:
Fax:	Cell Phone #
eMail:
Patient/Parent Employed By:
Present Position:
How Long Held:
Spouse/Parent Name:
Spouse Employed By:
Present Position:
How Long Held:
Who is Responsible for this account:
Drivers License No:
Method Of Payment:
Purpose of Call:
Other Family Members in this Practice:
Whom may we thank for this referral:
Patient/Parent Social Security No.:
Spouse/Parent Social Security No:
Someone to notify in case of emergency not living with you:

Primary Insurance
Employee Name:
Employer Name:	Yrs:
Name of Insurance Co.
Address:

Tel:
Program or Policy#
Social Security No:
Secondary Insurance
Employee Name:
Employer Name:	Yrs:
Name of Insurance Co.
Address:

Tel:
Program or Policy#
Social Security No:

Dental History

1. Purpose of initial visit:
2. Are you aware of a problem?
3. How long since your last dental visit?
4. What was done at that time?
5. Previous dentist's name:
	Address:Tel:
6. When was the last time your teeth were cleaned?
PLEASE CLICK THE APPROPRIATE ANSWER.
7. Have you made regular visits?	Yes No
8. Were dental x-rays taken?	Yes No
9. Have you lost any teeth or have any teeth been removed?	Yes No
10. Have they been replaced	Yes No
11. How have they been replaced?
12. Are you unhappy with the replacement?	Yes No
if yes, explain:
13. Would you like to know about permanent replacements?	Yes No
14. Have you ever had any problems or complications with previous dental treatment?	Yes No
if yes, explain:
15. Do you clench or grind your teeth?	Yes No
16. Does your jaw click or pop?	Yes No
17. Have you experienced any pain or soreness in the muscles or your face or around your ear?	Yes No
18. Do your have frequent headaches, neck aches or shoulder aches?	Yes No
19. Does food get caught in your teeth?	Yes No
20. Are any of your teeth sensitive to:
21. Do your gums bleed or hurt?	Yes No
When?
22. Do you experience dry mouth?	Yes No
23. how often do you brush you teeth?
24. Do you use dental floss?	Yes No
How often?
25. Are any of your teeth loose, tipped, shifted or chipped?	Yes No
26. Are you unhappy with the appearance of your teeth?	Yes No
27. How do you feel about your teeth in general?
28. Do you feel your breath is offensive at times?	Yes No
29. Have you ever had gum treatment or surgery?	Yes No
What?
Where?
When?
30. Have you had any orthodontic work?	Yes No
31. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?
32. Do you have any questions or concerns?	Yes No

Medical History

1. Physician's Name:
Address:
Tel:
2. Are you under a physician's care?	Yes No
3. When was your last complete physical exam?	Yes No
4. Are you taking any medications or substances?	Yes No
5. Do you routinely take health related substances?(vitamins, herbal supplements, natural products)	Yes No
6. Are you allergic to any medications or substances?	Yes No
Please List
7. Do you have any other allergies or hives?	Yes No
8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications?	Yes No
9. Are you sensitive to any metals or latex?	Yes No
10. Are you pregnant or suspect you may be?	Yes No
11. Do you use any birth control medications?	Yes No
12. Have you ever been treated for or been told you might have a heart disease?	Yes No
13. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?	Yes No
14. Have you ever had rheumatic fever?	Yes No
15. Are you aware of any heart murmurs?	Yes No
16. Do you have high or low blood pressure?	Yes No
17. Have you ever had a serious illness or major surgery?	Yes No
If so explain
18. have you ever had radiation treatment, chemo treatment for tumor growth or other condition?	Yes No
19. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphophonates) for bone tumor, excessive calcium in your blood, or osteoporosis?	Yes No
20. Do you have inflammatory diseases, such as arthritis or rheumatism?	Yes No
21. Do you have any artificial joints/prosthesis?	Yes No
22. Do you have any blood disorders, such as anemia, leukemia, etc?	Yes No
23. Have you ever bled excessively after being cut or injured?	Yes No
24. Do you have any stomach problems?	Yes No
25. Do you have any kidney problems?	Yes No
26. Do you have ay liver problems?	Yes No
27. Are you diabetic?	Yes No
28. Do you have fainting or dizzy spells?	Yes No
29. Do you have asthma?	Yes No
30. Do you have epilepsy or seizure disorders?	Yes No
31. Do you or have you had venereal or any sexually transmitted disease?	Yes No
32. Have you tested HIV positive?	Yes No
33. Do you have AIDS?	Yes No
34. Have you had or do you test positive for hepatitis?	Yes No
35. Do you or have you had T.B.?	Yes No
36. Do you smoke, chew, use snuff or any other forms of tobacco?	Yes No
37. Do you regularly consume more than one or two alcoholic beverages a day?	Yes No
38. Do you habitually use controlled substances?	Yes No
39. Have you had psychiatric treatment?	Yes No
40. Have you take any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?	Yes No
41. Do you have any disease condition, or problem not listed? if so explain.
42. Is there anything else we should know about your health that we have not covered in this form?
43. Would you like to speak to the doctor privately about any problem?	Yes No
BY CLICKING SUBMIT I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

Primary Insurance

Secondary Insurance

PLEASE CLICK THE APPROPRIATE ANSWER.

BY CLICKING SUBMIT I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE