Joyful Dental Care

6314 N. Cicero Ave. Chicago, IL 60646
(773) 736-7767

Medical History


Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physicianís care now?    Physicianís Name & Hospital:
Have you ever been hospitalized or had a major operation?    If yes, please explain:
Have you ever had a serious head or neck injury?    If yes, please explain:
Are you taking any medications, pills or drugs?    If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?   
When was your last A1C blood test?
Do you use tobacco?   
Do you use controlled substances?   
Women: are you...

Pregnant/Trying to get pregnant?     Taking oral contraceptives?     Nursing?

Are you allergic to any of the following?

If yes, please explain:

Do you have, or have you had, any of the following?
Alzheimerís Disease
AIDS/HIV Positive
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hepatitis A
Hepatitis B or C
High Blood Pressure
Hives or Rash
Irregular Heartbeat
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tumors or Growths
Venereal Disease
Yellow Jaundice

Have you ever had any serious illness not listed above?  

If yes, please explain:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patientís) health. It is my responsibility to inform the dental office of any changes in
medical status.

Patient or Guardian Name (Printed):     Date:

Patient or Guardian Signature: ___________________________________



How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is important that you answer each question as best you can.

SituationChance of Dozing (0-3)
Sitting and Reading
Watching TV
Sitting, inactive in a public place (e.g., a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
Your signature will be required.