(847) 516-1100

412 Crystal Street, Cary, IL 60013

Thomas J. Skleba, DDS, FAGD

Sarah S. Brewer, DMD

Call Us Today (847) 516-1100 Request Appointment

Welcome to Cary Dental Associates

Please complete and submit this form prior to your first visit. We look forward to working with you in maintaining your dental health.

Download / Printable PDF available below

Patient Form PDF Download

Analyze your smile

Patient History Form















YesNo





MF


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Dental Insurance

(Please bring a copy of your Dental Insurance Card. This may be different than your medical carrier. Please verify.)

















Dental History





(Please have x-rays forwarded to info@carydentalassociates.com prior to your first visit or new sets will be taken)

Cary Dental Associates, LLC

Eaglesoft Medical History




Although dental personnel primarily treat the area in your mouth, your mouth is a part of your entire body. Please list any health problems you may have or any medications that you are taking.

Are you under a physician's care now?
YesNo

Have you ever been hospitalized or had a major operation?
YesNo

Have you ever had a serious head or neck injury?
YesNo

Are you taking any medications, pills, or drugs?
YesNo

Do you take, or have you taken, Phen-Fen or Redux?
YesNo

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphonates?
YesNo

Are you on a special diet?
YesNo

Do you use tobacco?
YesNo

Do you use controlled substances?
YesNo

Women: Are you


YesNo

YesNo

YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther

Do you have, or have you had any of the following?

AIDS/HIV Positive
YesNo

Alzheimer's Disease
YesNo

Anaphylaxis
YesNo

Anemia
YesNo

Angina
YesNo

Arthritis/Gout
YesNo

Artificial Heart Valve
YesNo

Artificial Joint
YesNo

Asthma
YesNo

Blood Disease
YesNo

Blood Transfusion
YesNo

Breathing Problem
YesNo

Bruise Easily
YesNo

Cancer
YesNo

Chemotherapy
YesNo

Chest Pains
YesNo

Cold Sores/Fever Blisters
YesNo

Congenital Heart Disorder
YesNo

Convulsions
YesNo

Cortisone Medicine
YesNo

Diabetes
YesNo

Drug Addiction
YesNo

Easily Winded
YesNo

Emphysema
YesNo

Epilepsy or Seizures
YesNo

Excessive Bleeding
YesNo

Excessive Thirst
YesNo

Fainting Spells/Dizziness
YesNo

Frequent Cough
YesNo

Frequent Diarrhea
YesNo

Frequent Headaches
YesNo

Genital Herpes
YesNo

Glaucoma
YesNo

Hay Fever
YesNo

Heart Attack/Failure
YesNo

Heart Murmur
YesNo

Heart Pace Maker
YesNo

Heart Trouble / Disease
YesNo

Hemophilia
YesNo

Hepatitis A
YesNo

Hepatitis B or C
YesNo

Herpes
YesNo

High Blood Pressure
YesNo

High Cholestrol
YesNo

Hives or Rash
YesNo

Hypoglycemia
YesNo

Irregular Heartbeat
YesNo

Kidney Problems
YesNo

Leukemia
YesNo

Liver Disease
YesNo

Low Blood Pressure
YesNo

Lung Disease
YesNo

Osteoprosis
YesNo

Mitral Valve Prolapse
YesNo

Pain in Jaw Joints
YesNo

Parathyroid Disease
YesNo

Psychiatric Care
YesNo

Radiation Treatments
YesNo

Recent Weight Loss
YesNo

Renal Dialysis
YesNo

Rheumatic Fever
YesNo

Rheumatism
YesNo

Scarlet Fever
YesNo

Shingles
YesNo

Sickle Cell Disease
YesNo

Sinus Trouble
YesNo

Spina Bifida
YesNo

Stomach/Intestinal Disease
YesNo

Stroke
YesNo

Swelling of Limbs
YesNo

Thyroid Disease
YesNo

Tonsillitis
YesNo

Tuberculosis
YesNo

Tumors or Growths
YesNo

Ulcers
YesNo

Venereal Disease
YesNo

Yellow Jaundice
YesNo

Have you ever had any serious illness not listed 
YesNo


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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Analyze Your Own Smile

1. Would you like a whiter, more youthful smile?
YesNo

2. Do you see any defects in the appearance of your teeth or gums?
YesNo

3. Are there spaces or gaps between any of your teeth?
YesNo

4. Are your teeth crowded?
YesNo

5. If you have crowding or spaces is it getting worse?
YesNo

6. Are any of your teeth too long or too short?
YesNo

7. Are any of your teeth crooked, jagged, worn or chipped?
YesNo

8. Do you have any fillings/bondings that are chipped, discolored, misshaped, worn, or otherwise in need of upgrading?
YesNo

9. Do you have old veneers or crowns that need upgrading?
YesNo

10. Do you have any missing teeth that you would like replaced?
YesNo

11. Is the appearance of your smile out of balance from one side to the other?
YesNo

12. Is there anything else about your teeth/smile that you would like to change if it were possible?
YesNo

If you answered "yes" to any of these questions, would you like to discuss options for cosmetic dentistry with us?
YesNo

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