New Patients

Please take a few minutes to answer
 the health questions listed below.
Is Your General Health Good?
Yes        No
Have Allergies to Any Foods, Medications, Metals or Earrings?
Yes        No       If So, Which Ones?    
Do You Have or Have You Ever Had Any of the Following:
Heart Trouble?
High Blood Pressure?
Rheumatic Fever?
Heart Murmur?
Mirtal Valve Prolapse?
Leaky Heart Valve?
Infective Endocarditis?
Artificial Heart or Valve?
Artificial (Prosthetic) Joints?
Diabetes?
Antideperessant Medication?
Epilepsy?
Females: Are You Pregnant? 		Infected Artificial Joint?
Hemophilia?
Malnourishment?
Systemic Lupus Erythematosus?
Rheumatoid Arthritis?
HIV or AIDS?
Immunosuppression?
Radiation Therapy?
Asthma?
Bleeding Problems?
Hepatitis?
Have You Ever Taken Fen Phen?

Is There Any Other Information About Your Health
Which Should Be Known?   Yes       No
If So, What?  
Please List ALL Current Medications:
Physician's Name:
Physician's Address and Phone (If Known):
Patient Name:
Patient Phone:
Patient E-Mail:
Preferred Method of Contact:
Phone        E-Mail

*** THANK YOU FOR TAKING THE TIME TO FILL OUT THIS FORM.
AFTER SUBMITTING THIS HEALTH QUESTIONNAIRE, YOU CAN
NOW REQUEST AN APPOINTMENT ***
Notice of Privacy Practices
Ronald L. Schefdore, DDS is licensed as a general dentist in the state of Illinois providing cosmetic dentistry procedures.
Copyright © 2004 Ronald L. Schefdore, DDS. All rights reserved.
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