Joshua H. Ehrlich, DMD PC

3118 N. Sheffield Ave. Ste. 1N, Chicago IL 60657
(773) 935-0300

REGISTRATION FORM

Medical History

Check if you have or have had problems with any of the following:

AIDS/HIV Positive Emphysema Nasal Obstruction
Allergies Endocarditis Neurological Problems
Anemia Epilepsy Pacemaker
Angina Fainting or dizziness Psychiatric Care
Anxiety Fibromyalgia Radiation Treatment
Arthritis, Rheumatism Glaucoma Respiratory Disease
Artificial Heart Valves Headaches Rheumatic Fever
Artificial Joints Heart Attack Scarlet Fever
Asthma or Hay Fever Heart Murmur Shortness of Breath
Back Problems Heart Disease Seizures
Bleeding abnormally, with extractions or surgery Hemophilia Sinus Trouble
Blood Disease Hepatitis Type A Skin Rash
Blood Transfusion Hepatitis Type B Special Diet
Cancer Therapy Hepatitis Type C Stroke
Chemical Dependency Herpes Swollen Feet or Ankles
Chemotherapy High Blood Pressure Swollen Neck Glands
Circulatory Problems Jaundice Thyroid Problems
Claustrophobia Jaw Pain Tonsillitis
Congenital Heart Lesions Kidney Disease Tuberculosis
Contact Lenses Leukemia Tumor or growth on head or neck
COPD Liver Disease Ulcer
Cortisone Treatments Low Blood Pressure Venereal Disease
Cough, persistent or bloody Measles or Mumps Weight Loss, unexplained
Diabetes Mitral Valve Prolapse      

Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check the medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:

Presently taking
Taken in the past
History of reaction
Presently taking
Taken in the past
History of reaction
Presently taking
Taken in the past
History of reaction
Anesthetics, Locally Injected Codeine, Demerol, or other Analgesics Insulin or Diabetes Medication
Anesthetics, General Cortisone or Other Steroids Sedatives or Tranquilizers
Antacids Coumadin, Heparin, Warfarin or other blood thinners Sleeping Pills (Barbiturates)
Anti-anxiety Medications Dilantin Thyroid Medication such as Synthroid, Levoxyl, or Levothyroxine
Anti-depressants Diuretics (Water pills) Tylenol (Acetaminophen)
Antihistamines Fen-phen (Ionimin, adipax, Fastin, phentermine, Pondimin, fenfluramine, Redux, dexfenfluramine) Adverse reaction to any other medication or drug
Daily Aspirin Regimen Heart Medications such as Digoxin, Nitroglycerin, or Digitalis
Birth Control Pills Ibuprofen (Motrin)
Blood Pressure Medications                

List the other medications you are currently taking and what condition you are taking them for. Include vitamins, supplements, herbs and over the counter medications.

Phone:

Check your current use of:

Tobacco Yes No

Alcohol, Beer, Wine Yes No

Street Drugs Yes No

Caffeine Yes No

High Stress Yes No

Women: Are you pregnant: Yes No    Nursing? Yes No

Have you had any serious illnesses or surgeries: Yes No    If yes, describe:

Do you have any other health needs you should bring to our attention?

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Patient/Guardian signature _______________________________________

Date  _______________________________________________________

Please fill out this form and print it before your first appointment. Download PDF here.