(847) 516-1100

412 Crystal Street, Cary, IL 60013

Thomas J. Skleba, DDS

Sarah S. Brewer, DMD

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.


Yes   No

M   F

Married   Single   Divorced   Separated   Widowed

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?
Yes   No
Have you ever been hospitalized or had a major operation?
Yes   No
Have you ever had a serious head or neck injury?
Yes   No
Are you taking any medications, pills, or drugs?
Yes   No
Do you take, or have you taken, Phen-Fen or Redux?
Yes   No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphonates?
Yes   No
Are you on a special diet?
Yes   No
Do you use tobacco?
Yes   No
Do you use controlled substances?
Yes   No

Women: Are you

Pregnant/Trying to get pregnant?

Yes   No
Taking oral contraceptives?

Yes   No
Nursing?

Yes   No

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other?
If yes

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

AIDS/HIV Positive
Yes   No
Alzheimer's Disease
Yes   No
Anaphylaxis
Yes   No
Anemia
Yes   No
Angina
Yes   No
Arthritis/Gout
Yes   No
Artificial Heart Valve
Yes   No
Artificial Joint
Yes   No
Asthma
Yes   No
Blood Disease
Yes   No
Blood Transfusion
Yes   No
Breathing Problem
Yes   No
Bruise Easily
Yes   No
Cancer
Yes   No
Chemotherapy
Yes   No
Chest Pains
Yes   No
Cold Sores/Fever Blisters
Yes   No
Congenital Heart Disorder
Yes   No
Convulsions
Yes   No
Cortisone Medicine
Yes   No
Diabetes
Yes   No
Drug Addiction
Yes   No
Easily Winded
Yes   No
Emphysema
Yes   No
Epilepsy or Seizures
Yes   No
Excessive Bleeding
Yes   No
Excessive Thirst
Yes   No
Fainting Spells/Dizziness
Yes   No
Frequent Cough
Yes   No
Frequent Diarrhea
Yes   No
Frequent Headaches
Yes   No
Genital Herpes
Yes   No
Glaucoma
Yes   No
Hay Fever
Yes   No
Heart Attack/Failure
Yes   No
Heart Murmur
Yes   No
Heart Pace Maker
Yes   No
Heart Trouble / Disease
Yes   No
Hemophilia
Yes   No
Hepatitis A
Yes   No
Hepatitis B or C
Yes   No
Herpes
Yes   No
High Blood Pressure
Yes   No
High Cholestrol
Yes   No
Hives or Rash
Yes   No
Hypoglycemia
Yes   No
Irregular Heartbeat
Yes   No
Kidney Problems
Yes   No
Leukemia
Yes   No
Liver Disease
Yes   No
Low Blood Pressure
Yes   No
Lung Disease
Yes   No
Osteoprosis
Yes   No
Mitral Valve Prolapse
Yes   No
Pain in Jaw Joints
Yes   No
Parathyroid Disease
Yes   No
Psychiatric Care
Yes   No
Radiation Treatments
Yes   No
Recent Weight Loss
Yes   No
Renal Dialysis
Yes   No
Rheumatic Fever
Yes   No
Rheumatism
Yes   No
Scarlet Fever
Yes   No
Shingles
Yes   No
Sickle Cell Disease
Yes   No
Sinus Trouble
Yes   No
Spina Bifida
Yes   No
Stomach/Intestinal Disease
Yes   No
Stroke
Yes   No
Swelling of Limbs
Yes   No
Thyroid Disease
Yes   No
Tonsillitis
Yes   No
Tuberculosis
Yes   No
Tumors or Growths
Yes   No
Ulcers
Yes   No
Venereal Disease
Yes   No
Yellow Jaundice
Yes   No
Have you ever had any serious illness not listed  Yes   No     If yes, please explain:
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?
Yes   No
2. Do you see any defects in the appearance of your teeth or gums?
Yes   No
3. Are there spaces or gaps between any of your teeth?
Yes   No
4. Are your teeth crowded?
Yes   No
5. If you have crowding or spaces is it geting worse?
Yes   No
6. Are any of your teeth too long or too short?
Yes   No
7. Are any of your teeth crooked, jagged, worn or chipped?
Yes   No
8. Do you have any fillings/bondings that are chipped, discolored, misshaped, worn, or otherwise in need of upgrading?
Yes   No
9. Do you have old veneers or crowns that need upgrading?
Yes   No
10. Do you have any missing teeth that you would like replaced?
Yes   No
11. Is the appearance of your smile out of balance from one side to the other?
Yes   No
12. Is there anything else about your teeth/smile that you would like to change if it were possible?
Yes   No
If you answered "yes" to any of these questions, would you like to discuss options for cosmetic dentistry with us?
Yes   No
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