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Medical History Form

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MM slash DD slash YYYY

If Guardian/Caretaker:

If policy holder is someone other than the patient, please provide:

Are you currently under the care of a medical doctor?
Do you consume alcohol?
Do you use any non-prescription drugs or illicit substances? mood-altering drugs?
Do you currently smoke cigarettes, cigars, or vape?
Do you have any interest in quitting at this time?
Do you currently use chewing tobacco?
Have you ever had an unusual reaction to dental Novocaine?
After dental treatment, have you had bleeding problems?
Is there a history of diabetes in your family?
Are you on a prescribed diet?
Have you recently lost weight unintentionally?
Do injuries or cuts take longer to heal now than they did previously?
Do you have any rashes or lesions show up on your skin or in your mouth?
Does your mouth ever feel dry?
Do you get a burning sensation on your lips or tongue!
Have you taken or been given injections of steriods such as cortisone?
Have you ever been told to take antibiotics before dental appointments?
In the past 24 months, have you been prescribed steroids?
Have you been told to take antibiotics before dental appts?
Is there a possibility you clench or grind your teeth?
If yes, do you wear a nightguard?
Have you ever been diagnosed with Sleep Apnea?
If yes, do you wear a CPAP or nightguard?

Have you become sick from, shown an allergy to, or been told not to take:

Penicillin's or Amoxicillin?
Other antibiotics?
Codeine?
Novocaine or other dental anesthetics
Latex

Have you ever had any of the following:


(If yes, please add any details)

Heart disease or a heart attack
High blood pressure
Shortness of breath or tightness in the chest
Artificial or repaired heart valve
Bleeding trouble, anemia, leukemia
Blood transfusion
Asthma
Emphysema, COPD, chronic cough, or other lung trouble
Current or past history of Tuberculosis/T.B.?
Ulcer or Gastric bleeding history
Artificial joint or prosthesis
HIV Positive or AIDS
Seizure, Epilepsy, or fainting spells
Hepatitis, jaundice, liver disease
Kidney disease or Dialysis
Diabetes
Osteoporosis or Osteopenia history of bone density treatment?
Treatment for alcohol or drug dependency
Mental health condition
Recurrent cold sores or canker sores
Cancer, radiation or chemotherapy
Pregnant, breast feeding, or possibly pregnant
Autoimmune condition

I hereby acknowledge that all the above information is true and accurate

This field is for validation purposes and should be left unchanged.
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The mission of Periodontal Specialists is to improve the quality of life of our patients through the diagnosis and treatment of their periodontal disease and through rehabilitation with dental implants.

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