Northeast Periodontal Associates
Medical History
Patient Name:
Date Created
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have,
or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following:
Please list your primary care physician, referring dentist and preferred pharmacy with telephone numbers (if known):
Are you under a physician's care now:
Have you ever been hospitalized or had a
major operation?
Are you required to take an antibiotice prior
to dental work? If yes, which antibiotic?
Have you ever had a serious head or neck
injury?
Are you taking any medications, pills
supplements or drugs?
Do you take, or have you taken, Phen-Fen
or Redux?
Have you ever taken Fosamax, Boniva,
Actonel or any other medication
containing Bisphosphonates?
Do you use tobacco?
Do you use controlled substances?
Do you take any ED (Erectile Dysfunction
medications?
Women: are you:
O Yes O No
O Yes O No
If yes ______________________________________________________________
If yes ______________________________________________________________
O Yes O No
If yes______________________________________________________________
O Yes O No If yes_______________________________________________________________
O Yes O No If yes_______________________________________________________________
O Yes
O No
O Yes O No If yes_______________________________________________________________
O Yes
O Yes
O Yes
O No If Yes______________________________________________________________
O No If Yes _____________________________________________________________
O No If Yes_____________________________________________________________
O Pregnant/Trying to get pregnant?
Are you allergic to any of the following:
If yes_______________________________________________________________
O Aspirin
O Nursing?
O Penicillin
O Taking oral contraceptives?
O Codeine
O Acrylic
O Metal
O Latex
O Sulfa Drugs
O Local Anesthetics
Other Allergy? ___________________________________________________________________________________________
Do you have, or have you ever had, any of the following : (please circle Y (yes) or N (no)
AIDS
Angina
Asthma
Cancer
Congenital heart disorder
Drug addiction
Excessive bleeding
Frequent diarrhea
Heart attack/failure
Hemophilia
High blood pressure
Irregular heartbeat
Low blood pressure
Osteoporosis
Radiation therapy
Rheumatism
Sinus trouble
Swelling of limbs
Tumors or growths
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Alzheimer's
Arthritis/Gout
Blood disease
Chemotherapy
Convulsions
Easily winded
Excessive thirst
Frequent headaches
Heart murmur
Hepatitis A
High cholesterol
Kidney problems
Lung disease
Pain in jaw joint
Recent weight loss
Scarlet Fever
Spinal Bifida
Thyroid disease
Ulcers
Have you ever had any serious illness not listed?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Anaphlaxis
Artificial heart valves
Breathing problems
Chest pains
Cortisone medications
Emphysema
Fainting spells/dizziness
Glaucoma
Heart pacemaker
Hepatitis B or C
Hives or rash
Leukemia
Mitral valve prolapse
Parathyroid disease
Renal dialysis
Shingles
Stomach/intestinal disease
Tonsillitis
Venereal disease
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Anemia
Artificial joint
Bruise easily
Cold sores/Fever blisters
Diabetes
Epilepsy or seizures
Frequent cough
Hay fever
Heart trouble/disease
Herpes
Hypoglycemia
Liver disease
MRSA
Psychiatric care
Rheumatic Fever
Sickle Cell disease
Stroke
Tuberculosis
Yellow Jaundice
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
O Yes O No If yes, what?_________________________________________________________
What dental concern brings you to our office?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's)
health. It is my responsibility to inform the dental office of any changes in medical status.
___________________________________________________________________________________
Signature of Patient, Parent or Guardian:
____________________________________
DATE
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N