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Download Adult Health History - Perry Family Dental Care
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G. A. Perry, DDS and Associates Medical History Name_______________________________ Nickname ______________ DOB _________ M/F Date_______________ Please circle if you have/had: Bad Breath Blisters on Mouth/Lips Burning sensation on tongue Chew on one side of the mouth Cigarette, Pipe, Cigar use Smokeless Tobacco use Periodontal treatment/disease Head, neck or jaw pain Lip or Cheek biting Loose teeth or broken fillings Mouth Breathing Orthodontic treatment Nitrous Oxide Dental Implants Dry mouth Sensitivity to pressure Sensitivity to hot, cold, sweets Swollen, bleeding or tender gums Growths/sore spots in mouth Food collection between teeth Excessive bleeding Have you ever had an allergic reaction to any local or general anesthetics? Yes No Do you have or have you ever had any of the following, please circle: Acid Reflux Chemotherapy Hemophilia Alcohol/Drug Abuse Congenital Heart Defect Hepatitis Allergies/Hives Diabetes Type I High Blood Pressure Anemia Diabetes Type II HIV/AIDS Angina (chest pain) Emphysema Implants Anorexia/Bulimia Fainting/Seizures/Epilepsy Jaw Problems Arthritis/Rheumatism Frequent Headaches Kidney Problems Artificial Joints Glaucoma Leukemia Artificial Valves Heart Disease Liver Problems Asthma Heart Attack/Stroke Lyme Disease Cancer/Tumors Heart Surgery/Pacemaker Oral/Genital Herpes Psychiatric Problems Radiation Treatment Respiratory Problems Scarlet Fever Sickle Cell Disease Sinus Problems Sleep Apnea Stent/Shunt Thyroid Disease Tuberculosis Venereal Disease Do you have any disease or condition not listed above? _____________________________________________________ Do you have any allergies to any medications? Please list: ___________________________________________________ When you walk upstairs/take a walk, do you stop due to pain in your chest or shortness of breath ? Yes No Do your ankles swell during the day? Yes No Do you wake up from sleep short of breath? Yes No Have you ever been treated for osteoporosis or any other bone disorder? Yes No Are you now or have you ever taken Fosamax, Actonel or Boniva? Yes No WOMEN: Are you pregnant? Are you nursing? Are you practicing Birth Control? Do you anticipate becoming pregnant? Yes Yes Yes Yes No No No No Please List any Medications being taken: _______________________________________________________________________________ ________________________________________________________________________________________________________________________ To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in my health or medications, I will inform the dentist or dental staff at my next appointment. Patient Signature & Date_____________________________ Doctor Signature & Date____________________________ Emergency Contact Name and Phone Number ____________________________________________________________ Physicians Name and Number______________________________________ Date of Last Exam ____________________ EMAIL:_________________________________________ Effective September 2016
