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Name______________________

MEDICAL HISTORY
Name
Birth date
Please circle any of the following which you have or have had in the past
Do you require antibiotics before dental treatment? Y N PRE-MED DOSEAGE
Heart Conditions (Murmur, Rheumatic heart disease, Congenital defect, Mitral Valve Prolapse, Coronary Pregnant or breast-feeding currently (Women only) artery disease, Irregular heart beat, Congestive heart failure) , Heart Attack or other _________________ __________________________________________ Heart Procedures – Stents, Catheterization, Liver Disease (Cirrhosis, Hepatitis, Etc) Angioplasty, Pacemaker, Bypass surgery, Prosthetic Respiratory (Lung) Disease (Emphysema, Asthma, Type and Date of surgery ____________________ _________________________________________ Prosthetic joints or valves (Hip replacements, etc) Stroke / TIA’s Date: ________________________ Type/Date__________________________________ Blood Transfusions- Date _____________________ Arthritis (Rheumatoid, Osteo, Fibromyalgia, Gout) Y N Blood disorders (anemia, bleeding tendencies, etc) Allergies (hay fever, foods, materials, or medications) ___________________________________________ Stomach or Intestinal disease (GERD, Ulcers, Colitis, Diverticulitis, Hernia, Hiatal hernia) ___________________________________________ Date Diagnosed ___________________________ Glucose level _____________________________ History of Surgery, especially several repeated Procedures in childhood Cancer, Tumors, or Growths (include skin, benign etc) Type diagnosed _____________________________ Are you allergic to or unable to eat bananas, kiwis, avocados, chestnuts, tomatoes, potatoes, or Treatment __________________________________ Radiation therapy (X-ray treatments for Cancer) Do you have a heavy persistent cough of 2-3 weeks Area of Treatment __________________________ duration, particularly one that brings up sputum or Dose amount ______________________________ Infectious disease (AIDS, HIV, Herpes, Syphilis, Tuberculosis, Hepatitis A, B, or C or other) Date of Treatment ___________________________ Substance abuse (alcohol, cocaine, drugs, etc) Length of Treatment _________________________ Do you take or have you ever taken any of the
following: If yes for how Long? _______________ Fosamax or Fosamax plus D (Alendronate), TMJ (Jaw joint) problems or limited opening of mouth Actonel (Risedronate), Boniva (Ibandronate) Appliance? _________________________________ Zometa (Zolendronic acid), Didronel (Etidronate Organ Transplant __________________________ disodium) Didrocal, Aredia (Pamidronate), Bonefos Date of Transplant: __________________________ (Clondronate), Skelid (Tiludronate), Forteo Autoimmune disease such as Lupus, Pemphigus, Pemphigoid, Lichen Planus Have you experienced an allergic or unusual reaction to any of the following?
Please list any other drugs or materials that you are allergic to: _______________________________________________________ Name ________________________________
Date: _____________initials: _______ Continued Medical History
Your current physical health is: ___Excellent ___ Good ____ Fair ____ Poor Are you currently under the care of a physician? Y N Please explain: _________________________ Please list all physicians and their specialty Physician: ______________________________ List ALL medications you are taking and reason. Include prescription, supplements, and over the counter.
(Include any blood thinning herbal medications or supplements such as: Vitamin E, garlic, fish oil, any oils, bilberry, bromelain, cat’s claw, devil’s claw, dong quai, evening primrose, feverfew, ginger (at high doses), ginkgo biloba, grape seed, ginseng, green tea, horse chestnut, and turmeric.) Name of Medication
_______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. Name ________________________________
Date_____________
DENTAL HISTORY
Y N Did you visit your dentist within the last year? How often do you have your teeth cleaned? ______________________ Y N Are you dissatisfied with the appearance of your teeth? Y N Are you worried about having dental treatment? Y N Would it bother you to lose your teeth? Y N Would you be tremendously disturbed if you had to wear artificial teeth? Y N Do you clench or grind your teeth during the day or night? Y N Does your lower jaw click, snap, pop, or jump when you open? Y N Are your teeth sensitive to hot, cold, or sweets? Y N Do you use an electric Toothbrush? Brand ______________________ Y N Have you ever had orthodontic treatment? Date __________________ Y N Have you ever had periodontal treatment? Date __________________ Type – ___________________________________________ Areas Treated _____________________________________ Y N Are you on any special diet? Explain ___________________________ Y N Do you use tobacco in any form? Type_________________________ How Long ? _______________________________________ Special Considerations

Source: http://www.heartlandperiodontics.com/perio_medical_history.pdf

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