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Naperville Oral Surgery

Naperville
605 S Washington St
Naperville, IL 60540

Phone:
(630) 708-6637

Hours:
Mon–Fri: 8:00 AM–4:30 PM

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How did you hear about Naperville Oral Surgery and Dr. Foxson?
Financial Responsibility
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Are you in good health?
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Has there been any change in your general health in the past year?
Are you now under a physicians care for a particular problem?
Have you ever had/currently have any serious illnesses, operations, or hospitalizations?
Rheumatic Fever or Rheumatic Heart Disease?
Antibiotics?
Cogenital Heart Disease?
Anticoagulants/ Blood Thinners?
Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
High Blood Pressure Medications?
Cardiovascular Disease
Steroids Cortisone, Prednisone, etc?
Tranquilizers?
Insulin or Oral Anti-Diabetic Drugs?
Lung Disease
Digitalis, Inderal, Nitroglycerin, or other heart drug?
Seizures, Convulsions, Epilepsy, Fainting, or Dizziness
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily?
Liver Disease - Jaundice, Hepatitis?
Are you taking or have you ever taken bisphosphonates for osteoporosis, multiple myeloma, or other cancers?
Kidney Disease?
Have you been advised not to take a medication?
Diabetes?
Thyroid Disease or Goiter?
Arthritis?
Stomach Ulcers or Colitis?
Glaucoma?
Osteoporosis?
Implants placed anywhere in your body?
Radiation X-ray Treatment for Cancer?
Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grinding or clenching teeth?
Sinus or Nasal Problems?
Any disease, drug, or transplant operation that has depressed your immune system?
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Do you smoke or chew tobacco?
Allergic- Local Anesthesia, Novocain?
Allergic- Penicillin or other antibiotics?
Is there any past history of alcohol or chemical dependency or emotional disorder?
Allergic- Sedatives, barbiturates?
Allergic- Aspirin or Ibuprofen?
Have you had any serious problems associated with any previous dental or surgical treatment?
Allergic- Codeine or other pain killers?
Allergic- Latex or rubber products?
Have you or an immediate family member had any problem associated with intravenous or general anesthesia?
Allergic- Metal of any kind?
Allergic- Chemicals or jewelry rash or sensitivity?
Allergic- Food products?
Do you have any other disease, condition, or problem not listed above that you think the doctor should know about?
Allergic- Other allergies or reactions?
Do you wish to talk to the doctor privately about anything?
Have you ever had a bone density scan?
Are you pregnant or is there any chance you might be pregnant?
Are you nursing?
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