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LAKEWOOD PERIODONTICS Patient Name:_______________________________________________________________________ Address:___________________________________________________________________________ Home #:______________________ Work #:____________________ Cell #:_____________________ DOB:____________________ Height:_______________ Weight:_______________ General Dentist:___________________________ Phone#:________________Date of Last Dental Exam:_______________ Name of Physician:_________________________ Phone#:________________Date of Last Physical Exam:______________ Emergency Contact Info: Name:________________________________________ Relationship___________________________ Home #:______________________ Work #:____________________ Cell #:______________________ *****HEALTH INFORMATION***** 1. Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? ___________________ __________________________________________________________________________________________________ 2. Has there been any change in your general health within the past year? _______________________________________ __________________________________________________________________________________________________ 3. Are you under the care of a physician for a current problem? ________________________________________________ 4. Have you been hospitalized within the past 5 years? _______________________________________________________ 5. Have you received therapy for alcoholism or drug addiction during the past 5 years?_______________________________ 6. Have you ever had any ALLERGIC or ADVERSE REACTIONS to anesthetics, antibiotics or medications? _____________ ___________________________________________________________________________________________________ 7. Is there any condition concerning your health that the doctor should be told?______________________________________ 8. Do you wish to speak to the doctor privately about anything?__________________________________________________ 9. Have you had abnormal bleeding with previous extractions, surgery, or trauma?___________________________________ 10. Have you ever required a blood transfusion?_______________________________________________________________ 11. Have you ever had surgery and/or radiation for a tumor, growth, or other condition?________________________________ 12. Have you ever tested positively for HIV infection or AIDS? If so, state date diagnosed and treating Dr.:_________________ ___________________________________________________________________________________________________ 13. Before a dental appointment are you required to take premedication?____________________________________________ 14. Are you taking any herbal medicine? (i.e., St. Johns Wort)?___________________________________________________ 15. Do you have, or have you had any of the following? ____High Blood Pressure ____Sinus Trouble ____Heart murmur or prolapsed valve ____Thyroid problems ____Diabetes ____Joint prosthesis (hip, knee, etc.) ____Stomach ulcers, colitis ____Congenital heart disease ____Hepatitis, jaundice, liver disease ____Kidney problems ____Rheumatic fever or Rheumatic heart disease ____Cardiovascular disease: heart attack, stroke or bypass ____Prosthetic heart valve ____Psychiatric treatment ____Fainting spells or seizures ____Epilepsy ____Venereal disease ____Blood disorder (e.g., anemia) ____Cancer ____Asthma ____Temporomandibular joint problems (TMJ) ____Allergy to latex ____Low blood pressure ____Low blood sugar ____Dialysis ____Chest pain, angina ____Swollen ankles, arthritis or joint disease ____Irregular heart beat ____Contagious diseases ____X-Ray treatment or chemotherapy ____Heart surgery ____Delay in healing ____Hay fever or sinus problems ____Bronchitis, chronic cough ____Tuberculosis ____Problems with the immune system ____Emphysema ____Cardiac pacemaker ____Difficult breathing or other lung trouble ____Chronic fatigue or night sweats ____On a diet ____History of drug abuse ____History of alcohol abuse ____Wear contact lenses ____Eye disease or glaucoma ____Bruise easily ____Gallbladder trouble ____Infectious mononucleosis 16. Have you ever or do you currently smoke?? If yes, how long and how many?_____________________________________ 17. Have you ever taken "fen-phen"?________________________________________________________________________ 18. Do you have any disease, condition or problem not listed above?______________________________________________ 19. Are you taking bisphosphonates now or have you ever taken them in the past (Fosamax)?___________________________ 20. Please list any medication or drugs that you are taking:________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 21. WOMEN ONLY: Are you taking birth control pills?_______ Nursing?_______ Possibility of pregnancy?_________________ To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. I have also reviewed Lakewood Periodontics policy on Confidential Health Information and Privacy Practices. _____________________________________________________________________ Date:___________________________ Signature of patient (parent or guardian)
