General Health History - Periodontics of Southern Illinois

Name*

Age*

Date of Birth*

Please list your family physician and any medical specialists that you see at least once a year:

Are you in good general health?*

Yes
No

Are you currently under a physician’s care?*

Yes
No

For:*

Please list all prescription or over-the-counter drugs that you are taking and why:

Do you have (or have you ever had) Allergic reaction to drugs or latex*

Yes
No

Please Specify*

Latex
Penicillin
Aspirin
Codeine
Local Anesthetics
Other

Please Specify*

Do you currently take any of the following: Coumadin, Pradaxa, Warfarin, Effient, Eliquis, Plavix, Xarelto, Brilinta, Daily Aspirin*

Yes
No

Please Specify*

Coumadin
Pradaxa
Warfarin
Effient
Eliquis
Plavix
Xarelto
Brilinta
Daily Aspirin

Do you regularly take herbal medicines or dietary supplements?*

Yes
No

Specifically, do you take any of the following*

Have you undergone current or past osteoporosis therapy?*

Yes
No

Please Specify*

Fosamax
Actonel
Boniva
Reclast
Prolia

If so, how long have you been on the medication?*

Have you undergone current or past therapy to reduce high blood calcium? Bisphosphonate chemotherapy utilizing intravenous Aredia and Zometa*

Yes
No

Heart attack or heart disease*

Yes
No

High blood pressure*

Yes
No

Artificial heart valve*

Yes
No

Bacterial endocarditis*

Yes
No

Any condition that requires antibiotic pre-medication before dental treatment*

Yes
No

Please Specify

Artificial joints*

Yes
No

Please Specify*

Hip
Knee
Ankle
Shoulder

Dates placed:*

Immunosuppressive condition*

Yes
No

Please Specify*

Steroid Therapy (e.g. Prednisone)
Radiation Therapy
Cancer Therapy
Lupus Rheumatoid Arthritis
HIV
Organ Transplant
Spleen Removed
Other

Bleeding problem; anemia or other blood disease*

Yes
No

Diabetes*

Yes
No

If so, is it controlled?*

Yes
No

Thyroid disease*

Yes
No

Asthma*

Yes
No

Stomach Trouble*

Yes
No

Hepatitis*

Yes
No

Kidney disease*

Yes
No

Liver disease*

Yes
No

Mental Health condition*

Yes
No

Please Specify*

Do you have or have you ever been treated for cancer?*

Yes
No

Please Specify*

Do you smoke?*

Yes
No

How much*

Do you use smokeless tobacco?*

Yes
No

How interested are you in stopping your tobacco use?*

Very interested
Somewhat interested
Not at all interested

Do you drink alcohol?*

Yes
No

How often?*

Occasionally
Daily

Do you have any disease, condition or problem not listed here?*

Yes
No

Please Specify*

WOMEN:

Are you or could you be pregnant?*

Yes
No

What trimester?*

Breast feeding?*

Yes
No

Taking oral contraceptives?*

Yes
No

REMINDER: USE OF ANTIBIOTICS MAY CAUSE DECREASED EFFECTIVENESS OF ORAL CONTRACEPTIVES

Do you have (or have you ever had) any of the following?

Dental pain*

Yes
No

Bleeding Gums*

Yes
No

Sores or Lumps in your mouth*

Yes
No

Persistent Headaches or Earaches*

Yes
No

Would you be distressed if you had to wear dentures?*

Yes
No

Do you want to save your teeth?*

Yes
No

Are you happy with the appearance of your teeth?*

Yes
No

Are you allergic to any metals or dental materials?*

Yes
No

Please circle the types of dental treatment you have experienced.

Orthodontics (braces)
Root Canal
TMJ treatment
Periodontal (gum)Treatment
Dental Implants
Crowns
Bridges
Dentures

OFFICE POLICY AND TREATMENT CONSENT

I hereby certify that the foregoing information is correct. I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending periodontist or supervised staff for diagnostic purposes or dental treatment. I give permission for any insurance payments to be made directly to the providing periodontist. I give my permission to contact necessary professionals concerning my current health, past dental and medical treatment, and recommended dental treatment. Furthermore, I will be responsible for any financial obligations incurred for dental treatment . I understand that any outstanding balance is subject to a two percent (2%) monthly finance charge. In the event that I fail to uphold my financial obligations, I am aware that I will be responsible for all reasonable costs of attorney’s fees incurred in the collection of my outstanding balance.