Joshua H. Ehrlich, DMD PC

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

REGISTRATION FORM

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

Medical History

Patient name Birth date: ID #

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

AIDS/HIV Positive	Yes	No	Emphysema	Yes	No	Nasal Obstruction	Yes	No
Allergies	Yes	No	Endocarditis	Yes	No	Neurological Problems	Yes	No
Anemia	Yes	No	Epilepsy	Yes	No	Pacemaker	Yes	No
Angina	Yes	No	Fainting or dizziness	Yes	No	Psychiatric Care	Yes	No
Anxiety	Yes	No	Fibromyalgia	Yes	No	Radiation Treatment	Yes	No
Arthrities, Rheumatism	Yes	No	Glaucoma	Yes	No	Respiratory Disease	Yes	No
Artifical Heart Vales	Yes	No	Headaches	Yes	No	Rheumatic Fever	Yes	No
Artificial Joints	Yes	No	Heart Attack	Yes	No	Scarlet Fever	Yes	No
Asthma or Hay Fever	Yes	No	Heart Murmur	Yes	No	Shortness of Breath	Yes	No
Back PRoblems	Yes	No	Heart Disease	Yes	No	Seizures	Yes	No
Bleeding abnormally, with extractions or surgery	Yes	No	Hemophillia	Yes	No	Sinus Trouble	Yes	No
Blood Disease	Yes	No	Hepatitis Type A	Yes	No	Skin Rash	Yes	No
Blood Transfusion	Yes	No	Hepatitis Type B	Yes	No	Special Diet	Yes	No
Cancer Therapy	Yes	No	Hepatitis Type C	Yes	No	Stroke	Yes	No
Chemical Dependency	Yes	No	Herpes	Yes	No	Swollen Feet or Ankles	Yes	No
Chemotherapy	Yes	No	High Blood Pressure	Yes	No	Swollen Neck Glands	Yes	No
Circulatory Problems	Yes	No	Jaudice	Yes	No	Thyroid Problems	Yes	No
Claustrophobia	Yes	No	Jaw Pain	Yes	No	Tonsillitis	Yes	No
Congential Heart Lesions	Yes	No	Kidney Disease	Yes	No	Tuberculosis	Yes	No
Contact Lenes	Yes	No	Leukemia	Yes	No	Tumor or growth on head or neck	Yes	No
COPd	Yes	No	Liver Disease	Yes	No	Ulcer	Yes	No
Cortisone Treatments	Yes	No	Low Blood Pressure	Yes	No	Venereal Disease	Yes	No
Cough, persistent or bloody	Yes	No	Measles or mumps	Yes	No	Weight Loss, unexplained	Yes	No
Diabetes	Yes	No	Mitral Valve Prolapse	Yes	No

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 medicaitons 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
Anestetics, 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 (Acetomeniphen)
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 Digitalls				Please specify:
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.

Pharmacy name: Phone:

Check your current use of:

Tobacco Yes No Packs per day Alcohol, Beer, Wine Yes No Drinks per day

Street Drugs Yes No Times per day Caffine Yes No Cups per day

High Stress Yes No Reason

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 heath 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  _______________________________________________________