Michael Papendick DDS | Cosmetic Family General Dentist | Waukegan, IL

New Patient Registration Forms

Before your first visit, you will need to complete our new patient registration forms. Please make sure that you complete it in its entirety and click “submit” at the end of the form. These forms take a long time to fill out, so please give yourself enough time. If they are not filled out before your first visit, it will cut into your appointment time with Dr. Papendick.

Each patient is required to have their own forms. When you come in for your first visit, we will already have your submitted forms here awaiting you! If you are not able to do this on your computer ahead of time please call the front desk and we will send them to you in the mail. If your appointment date does not allow for for the forms to be mailed, please come in for your appointment 30 minutes early, and we will provide you with the appropriate forms to fill out.

Patient Registration and Health History
Patient Name ( Last, First, Middle Initial)
Sex
m f
Age
Home phone number (required)
Work phone number
Cell phone number
Address ( including City, State, Zip)(required)
Email address(valid email required)
Reason for visit(required)
Has any family member received treatment in this office?
How did you hear about us?(required)
What is the best appointment time for you?
Morning Afternoon
Evening
Emergency contact (not living with you)
Name(required)
Phone number(required)
Address ( including City, State, Zip)(required)
Responsible party
Name ( last, first, MI)(required)
Mailing Address (required)
How long at this address?
Home phone number ( if none, enter none)(required)
Cell phone number ( if none, enter none)(required)
Previous address (if less than 3 years)
Employer(required)
Occupation(required)
Number of years employed(required)
SSN(required)
Date of birth(required)
Driver's license number
Marital status
Married Single
Divorced Widowed
Dental Insurance
Insured's name( if same as above, enter "same")(required)
Occupation ( if same as above, enter "same")(required)
Number of years employed ( if same as above, enter "same")(required)
SSN ( if same as above, enter "same")(required)
Date of birth ( if same as above, enter "same")(required)
Work phone ( if same as above, enter "same")(required)
Insured's employer (if same as above, enter "same")(required)
Insurance company(required)
Insurance company address(required)
Group number(required)
Local number
Dental History
How long since you have been to a dentist?(required)
Last complete dental exam? ( date)(required)
Name of previous dentist
Previous dentist's address
How do you feel about your teeth? (required)
If you could change anything about your teeth, what would it be?(required)
Please rank the following in order in which they would prevent you from having dental treatment ( 1-4).
Fear of pain
1 2
3 4
Lack of concern
1 2
3 4
Cost of treatment
1 2
3 4
Missing work time
1 2
3 4
Are you currently having problems?
yes no
What are those problems?(required)
Is your present dental health poor?
yes no
Do you wear dentures? (partial or full)?
yes no
Are you happy with your dentures?
yes no
Are you interested in permanent replacements?
yes no
Are you apprehensive about dental treatment?
yes no
Have you had and periodontal (gum) treatments?
yes no
Are your teeth sensitive to hot, cold, sweets, pressure?
yes no
Are you unhappy with the appearance of your teeth?
yes no
Are you aware of grinding or clenching your teeth?
yes no
Do you have headaches, earaches, or neck pain?
yes no
Have you worn braces on your teeth ( orthodontics)?
yes no
Do you have discolored teeth that bother you?
yes no
Would you like your smile to look better or different?
yes no
Do you regularly use dental floss?
yes no
General Health History Please choose yes or no if you currently suffer from any of the following, and list conditions if necessary ( at end of questions):
Cardiovascular disease ( heart trouble, heart attack, stroke, coronary insufficiency, damaged coronary heart valves, heart murmur, artificial heart valve)
yes no
Kidney trouble
yes no
High blood pressure
yes no
Low blood pressure
yes no
Tuberculosis
yes no
Diabetes
yes no
Glaucoma
yes no
Abnormal bleeding associated with previuos surgery, extraction, or trauma
yes no
Any condition that would require pre-medication ( such as knee/hip replacement)
yes no
Any other disease, condition, or problem not listed above that we should know about
yes no
Please us this area to explain any conditions or tell us about something not listed.
Are you currently under a physician's care
yes no
if yes, for what condition?
What medications or drugs are you currently taking ( including non-prescribed or street drugs) ? ( if none, answer "none")(required)
Are you allergic to, or have had adverse reactions to any drugs or medications
yes no
If yes, please list drugs or medications
Women Only: Are you pregnant?
yes no
Are you nursing?
yes no
The Epworth Sleepiness Scale The Epworth Sleepiness Scale(ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self administered questionnaire,widely used by sleep professionals in quantifying the level of daytime sleepiness.
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling "just tired"? This refers to your usual way of life at present or in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for the situation.
0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing
sitting and reading
0 1
2 3
watching tv
0 1
2 3
sitting, inactive in a public place
0 1
2 3
as a passenger in a car for an hour without a break
0 1
2 3
lying down to rest in the afternoon when circumstances permit
0 1
2 3
sitting and talking to someone
0 1
2 3
sitting quietly after lunch without alcohol
0 1
2 3
in a car, while stopped for a few minutes in traffic
0 1
2 3
TMJ questionnaire These questions are useful in identifying jaw joint disorders and related headaches.
Do you have difficulty or pain in opening your mouth?
yes no
Is your jaw stiff, tight or tired?
yes no
Do you have difficulty or pain when chewing?
yes no
Do you have either 'clicking" or "popping" in either jaw joint?
yes no
Do you have headaches or facial pain?
yes no
Do you clench or grind your teeth during the day or night?
yes no

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