Perio Medical History Form

MEDICAL HISTORY

Patient Name

Birth Date

Please select YES or NO to the following medical questions below

Do you require antibiotics before dental treatment?

Y N

PRE-MED DOSAGE

BP:

Pulse:

Date:

Initials:

Continued Medical History

Local anesthetic
(Novocain)

Please list any other drugs or materials that you are allergic to:

Excellent Good Fair Poor

Please list all physicians and their specialty:

Family Physician:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name

Date

Dental History

Y N

Did you visit your dentist within the last year?

How often do you have your teeth cleaned?

Last cleaning date

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 your gums bleed easily?

Y N

Do your gums feel tender?

Y N

Does your mouth feel dry?

Y N

Do you have difficulty swallowing?

Y N

Do you clench or grind your teeth during the day or night?

Y N

Do your teeth feel loose?

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 a special diet? Explain

Y N

Do you use tobacco in any form? Type

How Long?

Special Considerations

Office Use Only