PATIENT MEDICAL HISTORY

Name ______________________________________________________________________ Date _____________________

Referring Dentist _______________________________________ Physician __________________________________________

Birth Date ________________ Age ______ Height _______ Weight _______ Preferred Pharmacy_____________________________

Sex: Male Female Occupation_________________________________________________________________

Are you currently under medical treatment?If yes, please explain _______________________

Have you ever been hospitalized for a surgical operation or serious illness within the past 5 years? If yes, please explain

____________________________________

Do you use tobacco, nicotine or marijuana products?

Do you use any controlled substances?

Are you allergic to or had any reactions to the following:Local anesthetics (e.g. novocaine) Penicillin or other antibioticsLatex rubberOther _______________________

Are you or could you be pregnant?Are you nursing?Are you taking oral contraceptives?

1.

2.

5.

6.7.8.

3.

4.

YES NO YES NO

Please list any medications you are taking (including non-prescription medications, vitamins, minerals, and herbal remedies)

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Please check any of the following which you have had or have at present : Low Blood Pressure High Blood Pressure Heart Attack/StrokeArti�cial Heart Valve Heart Disease/AnginaCardiac PacemakerBleeding DisordersHeart Murmur w/RegurgitationRheumatic Fever

Circulatory ProblemsArthritisAsthmaEpilepsy/ConvulsionsDiabetes/Kidney DiseaseThyroid ProblemsSinus IssuesTuberculosisAnemia

Joint ReplacementHepatitis/JaundiceAIDS or HIV InfectionStomach Troubles/UlcersRespiratory Problems/EmphysemaCancer/Radiation/ChemotherapyOsteoporosis/OsteopeniaCold SoresOther ________________________

PATIENT DENTAL HISTORYDo your gums bleed while brushing or �ossing?Are your teeth sensitive to hot or cold liquids/food?Do you feel pain in any of your teeth?Do you have any sores or lumps in or near your mouth?Have you had any head, neck, or jaw injuries?

Do you clench or grind your teeth?Have you ever had any di�cult extractions in the past?Have you ever had any prolonged bleedingfollowing extractions?Have you had any orthodontic treatment?

The above information is accurate to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for bene�ts for which I am entitled. I will not hold my doctor or any member of his/her sta� responsible for any errors or omissions that I may have made in the completion of this form. I accept any mutually-agreed upon dental anesthetics or treatment that Periodontal Health Specialists feels are necessary in my case.

Signature ____________________________________________________________Date ___________________

D R . M I C H A E L J . F L O R E N C E D R . J A C K H . L I N C K S D R . R A N D Y S . D E M E T T E R

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