Medical History

Online

Medical History Form

Lawrence H. Zager, D.D.S.,P.C.

25 E. Washington Suite 825

Chicago, IL 60602

ph: 312-372-0411 fax: 1-312-372-0428

Patient Information

* indicates a required field

First Name: *

Last Name: *

Birth Date:

(mm/dd/yyyy) Gender:

Email Address:

Address Line 1:

Pref. Phone: *

Home Work Cell

Address Line 2:

Home Phone:

City:

Work Phone:

State:

Zip:

Cell Phone:

Check here to save your personal information on this computer

Dental Questions Medical Questions Allergies Medical Hist. (pt. 1)Medical Hist. (pt. 2)

Dental Questions

How long since you have seen a dentist?

1 year 2 years 3 years 4 years 5+ years

Date of last complete dental exam:

(mm/dd/yyyy)

Date of last full mouth x-rays:

(mm/dd/yyyy)

Are you having problems now?

Yes No

If Yes:

Is your present dental health good?

Yes No

Do you wear dentures?

No Yes - Partial Yes - Full

Are you unhappy with your dentures?

Yes No

Would you like permanent replacements?

Yes No

Are you apprehensive about dental treatment?

Yes No

Name of Previous Dentist:

Prev. 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:

1 2 3 4 5

Cost of Treatment:

1 2 3 4 5

Lack of Concern:

1 2 3 4 5

Missing Work Time:

1 2 3 4 5

Have you had any periodontal (gum) treatments?

Yes No

Do your gums bleed or feel tender or irritated?

Yes No

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

Yes No

Are you unhappy with the appearance of your teeth?

Yes No

Are you aware of grinding or clenching your teeth?

Yes No

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

Yes No

Have you worn braces on your teeth (orthodontics)?

Yes No

Do you have discolored teeth that bother you?

Yes No

Would you like your smile to look better or different?

Yes No

Do you regularly use dental floss?

Yes No


Dental Questions Medical Questions Allergies Medical Hist. (pt. 1)Medical Hist. (pt. 2)

Copyright © 1983-2009 MOGO, Inc. All rights reserved. MOGO, MOGO Windows, MOGO Dental Software, MOGO Dental Practice Management Software, and MOGO SQL are registered trademarks of MOGO, Inc. Other brand and product names are trademarks or registered trademarks of their respective owners. This document is subject to change without notice and does not represent a commitment on the part of MOGO, Inc. Clinical Documentation Code (CDT), copyright © American Dental Association (ADA). All rights reserved.