Dentistry for the Fearful and More
609 E. Sibley Blvd. (147th), Dolton, IL 60419   | Directions

Patient Information Form

Please note that it is important to fill in all the fields before submitting. Thank you.

About You

Patient Name :
Last Name*
Middle Name First Name*
Social Security #:*
Patient's Birthday:*
Parent/Guardian's name:
Spouse name :
Home Address:*
Home Phone:* ()--
Work Phone: ()---
Cell Phone : ()--
How did you hear about us?
Whom may we thank for this referral?
In Case of Emergency, Contact Details -
Contact Name: Phone #: ()--

Health and Dental History

Physician's Name: Phone #: ()--
Are you taking any medication now, including regular dosages of aspirin, vitamins, herbs, etc ? Yes No
If yes, please list name and dosage :
Are you allergic to any medications or substances ?
Penicillin Latex Codeine Metals Sulfa
Food or Others please list :
Have you been under the care of a medical doctor during the past two years ? Yes No
If so, for what ?
Indicate which of the following you have had, or have at present -
Rheumatic Fever Yes No Headaches Yes No
Heart Concerns Yes No Braces Yes No
Congenital Heart Disease Yes No Jaw Pain Yes No
Heart Murmur Yes No Jaw Popping Yes No
High Blood Pressure Yes No Limited Jaw Opening Yes No
Mitral Valve Prolapse Yes No Loose Teeth Yes No
Stroke Yes No Bleeding Problems Yes No
Asthma / Respiratory Disorder Yes No Clenching Yes No
Anemia / Blood Disorder Yes No Grinding Yes No
Liver Disease / Jaundice Yes No Sensitive Teeth Yes No
Tuberculosis Yes No Difficulty Chewing Yes No
Artificial Joints Yes No Insomnia / Frequent waking Yes No
Kidney Trouble Yes No Psychiatric / Psychological Yes No
Radiation / Chemotherapy Yes No Neurological Disorders Yes No
Epilepsy / Seizures Yes No Snoring Yes No
Hepatitis A B C Yes No AIDS / HIV Yes No
Indicate which of the following you have had, or have at present -
Does the thread shred when you floss ? Yes No
Do you like to improve your smile? Yes No
Do you feel pain in any of your teeth? Yes No
Do food particles catch between your teeth ? Yes No
Do you smoke ? Yes No
Would you be interested in preventing bad breadth? Yes No
Do you use Chewing Tobacco? Yes No
Do you ever get a bad taste in your mouth? Yes No
Do your gums bleed ? Yes No
Do you have any sores or lumps in or near your mouth? Yes No
Does your breath concern you ? Yes No
Have you ever had any difficult extractions in the past? Yes No
Have you ever worn braces? Yes No
Do you wear dentures / partials? If yes date of placement? Yes No
Have you noticed any loose teeth or change in your bite? Yes No
Would you be interested in straightening your teeth without having braces? Yes No
If you could easily and safely whiten your teeth, would you be interested? Yes No
Do you have or have had any disease, condition or problem not listed above ?
Have you ever undergone any cosmetic procedure(s) ? Yes No
If yes please give details :
Female Patients -
Are you Pregnant ? Yes No
Are you Nursing ? Yes No
Are you Taking Birth Control Pills ? Yes No

New Patient Questionnaire

Our office is like no other dental office. This will be the most important dental visit you will ever have. We place a high emphasis on helping you determine your present and future dental needs. Here are some things we will be talking about at your first visit. These are issues you have probably never thought of. Please explain or choose what best expresses how you feel about the following questions.
What are your areas of concern?
In your opinion, what is the status of your oral health at this time?
Do you have any family friends who already come to our office? Yes No
What do you already know about our office and what are your expectations?
How healthy do you want your oral health to be? Don't really care Average Ideal/The best
What quality of dentistry do you want us to recommend? Just patch it up Ideal/ The best
If you had a magic wand, what might you change, if anything, about your smile?
Has fear ever been an issue for you in a dental office? Yes No
Why did you leave your last dental office?
Has time ever been a factor in getting your dental work done? Yes No
Has the cost of dental treatment been a concern for you? Yes No
Is there any additional information you would like us to know?
* I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, which may release such information to you. I will notify the doctor of any change in my health or medication. Pleasant Dental may use all records and photographs for purpose of education or publication. Consent for treatment I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my and/or my child's dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and employ such assistance as required providing proper care. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.


Office Hours

Monday to Saturday - 8am - 6pm

Contact via phone, email, or through our convenient online form. We will respond to you as quickly as possible.

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Pleasant Dental located at 609 E. Sibley Blvd. (147th), Dolton, Illinois 60419 | Phone: 708-315-6343 |
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