Perio Specialist - Existing Patient

Are you in good health?

Yes

Height

inchs

Weight

lbs

Are you under care of a physician?

Yes

Have you taking antibiotics prior to dental treatment?

Yes

Have you been hospitalized in the past five years?

Yes

Have you ever had general anesthesia?

Yes

Have you or your family had reactions to general anesthesia?

Yes

Have you had the COVID vaccination?

Yes

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Prolia, Xgeva, or Evista in the past 12 years?

Yes

Women Only

Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

1) Is there a possibility of pregnancy?

Yes

2) Expected delivery date

3) Are you nursing?

Yes

4) Are you taking birth control pills?

Yes

Penicillin

Yes

Sulfa drugs

Yes

Local anesthetic

Yes

Amoxicillin

Yes

Aspirin

Yes

Codeine or other narcotics

Yes

Latex

Yes

Do you have any known allergies

Yes

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

AIDS / HIV

Yes

Dementia

Yes

High blood pressure

Yes

Prosthetic implant

Yes

Alzheimer’s

Yes

Diabetes

Yes

High cholesterol

Yes

Radiation

Yes

Anemia

Yes

Do you smoke or vape

Yes

History of alcohol / drug abuse

Yes

Respiratory problems

Yes

Arthritis / Joint disease

Yes

Number of smoke/day

History of marijuana / drug use

Yes

Rheumatic fever

Yes

Asthma

Yes

Do you use chewing tobacco

Yes

Infectious mononucleosis

Yes

Sexually transmitted diseases

Yes

Bleeding tendency

Yes

Emphysema

Yes

Irregular heart beat

Yes

Sleep apnea / CPAP

Yes

Blood transfusion

Yes

Eye disease / Glaucoma

Yes

Joint replacement

Yes

Special diet

Yes

Bronchitis

Yes

Fainting spells

Yes

Kidney trouble

Yes

Stomach ulcers / acid reflux

Yes

Bruise easily

Yes

Hay fever / Sinus problems

Yes

Liver disease

Yes

Stroke

Yes

Cancer

Yes

Heart attack(s)

Yes

Low blood pressure

Yes

Thyroid trouble

Yes

Chest pain / Angina

Yes

Heart murmur

Yes

Low blood sugar

Yes

Trouble climbing 1-2 flights of stairs

Yes

Chronic cough

Yes

Heart pacemaker

Yes

Mental health problems

Yes

Tumor or growth

Yes

Chronic fatigue / Night sweat

Yes

Heart surgery

Yes

Osteopenia

Yes

Convulsions / Epilepsy

Yes

Heart trouble

Yes

Osteoporosis

Yes

COVID–19

Yes

Heart valve issues

Yes

Pneumonia

Yes

Delay in healing

Yes

Hepatitis

Yes

Problems with immune system

Yes

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products). Please note: You can add a maximum of 8 medications in this form.

I certify I have read and I understand the questions. I acknowledge my questions have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her team, responsible for any errors or omissions that I have made in the completion of this form.

Medical History

Patient Information

Medical History

Women Only

Allergies/Reactions

Medical Conditions

Medications