(847) 516-1100

412 Crystal Street, Cary, IL 60013

Thomas J. Skleba, DDS, FAGD

Sarah S. Brewer, DMD

Pay Online
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

    MarriedSingleDivorcedSeparatedWidowed


    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
    After hitting submit once, please wait for a confirmation message that we've received your form before closing your browser window.