EPIC PERIO Medical History Form

Health History

Please fill out this form as complete as possible.
Date*

MonthDayYear
Patient Name*

First NameLast Name
Age*
Patient Birth Date*

MonthDayYear
Gender*
1. Are you now or have you been under a physician's care including routine care?*

YesNo
If yes, please explain:
2. When was your last physical?

MonthDayYear
Date
3. Have you EVER had an illness that required HOSPITALIZATION or SURGERY?*

YesNo
If yes, please list ALL and DATES:
4. Are you currently under a doctor's orders or taking any DRUGS or MEDICATIONS? including birth control pills, diet pills, over the counter drugs, herbal supplements, or homeopathic preparations?*

YesNo
If yes, please list ALL and DOSAGE:
5. Do you have any ALLERGIES or sensitivities to any drugs or substances such as local, sedation or general anesthetics, penicillin, aspirin, codeine, latex or others?*

YesNo
If yes, please list ALL ALLERGIES
6. Do you have any heart problems, palpitations, heart murmur, chest pain, heart attack, heart surgery, pacemaker, defibrillator, valve replacement, angioplasty, filters, heart bypass or stents?*

YesNo
If yes, please explain
7. Have you ever had any breathing difficulty including asthma, emphysema, chronic cough, pneumonia, tuberculosis, snoring, or sleep apnea, or daytime sleepiness?*

YesNo
If yes, please explain
8. Do you have to stop when walking up a flight of stairs?*

YesNo
9. Are you subject to fainting, dizziness, nervous disorders, seizures, epilepsy or stroke?*

YesNo
If yes, please explain
10. Have you had cancer, chemotherapy or radiation therapy?*

YesNo
If yes, please explain
11. Have you ever bled excessively after a cut, wound or surgery?*

YesNo
If yes, please explain
12. Do you have or been told that you have popping, clicking jaw joints or TMJ problems?*

YesNo
If yes, please explain
13. Do you have any muscle spasms or pain associated with your face or jaws?*

YesNo
14. Have you ever taken the diet pills Phen-Fen, Redux or Pondimin?*

YesNo
(E.G. Fenfluramine or Dexfenfluramine) please list and explain
15. Do you currently use or have a history of using recreational drugs?*

YesNo
If yes, please explain
16. Are you positive for HIV (Human Immunodeficiency Virus), AIDS or AIDS related complex?*

YesNo
17. Are you taking any MAO INHIBITOR Antidepressant drugs including Parnate (Tranylcypromine), Nardil (Phenelzine), or Marplan (Isocarboxazid)?*

YesNo
If yes, please list and explain
18. Have you ever been treated or currently being treated for osteoporosis, multiple myeloma, breast cancer, Paget's disease or other bone affecting disease?*

YesNo
If yes, please explain
19. Have you ever taken or currently taking any intravenious or oral BISPHOSPHONATES (bone retaining) medications including Aredia (Pamidronate), Reclast or Zometa (Zoledronate), Bonefos (Clodronate), Didronel (Etidronate) Boniva (Ibandronate), Fosamax (Alendronate), Actonel (Risedronate) or Skelid (Tiludronate), or others?*

YesNo
If yes, please list and explain
20. WOMEN: Are you pregnant?*

YesNo
If yes, number of months
Are you breast-feeding your baby?

YesNo
21. Is there anything else you need to explain about your current health or past health history?*

YesNo
If yes, please and explain
Have you ever had (Please check all that apply)

Congenital Heart DiseaseEndocarditis (Heart Infection)Heart Valve ReplacementHeart (Coronary) Bypass or StentsBlood Vessel Stents or FiltersChest Pain (Angina)Pacemaker or DefibrillatorHeart Murmur / Mitral Valve ProlapseRheumatic FeverCongestive Heart FailureSwollen AnklesLupus (Erythematosis)Low Blood PressureHigh Blood PressureStokeAnemiaSickle Cell TraitPorphyriaJaundice or Liver DiseaseBleeding DisorderBlood ThinnersBlood TransfusionAccutane (for acne)Embolism or Blood ClotsJoint ReplacementRheumatoid ArthritisLeukemia / LymphomaShortness of BreathAsthmaThyroid DiseaseStomach Ulcer, Reflux or BypassKidney DiseaseSeizuresPsychiatric CareGlaucomaOsteoporosisSteroids or Immune Suppression DrugsOrgan TransplantSinusitisDrug or Substance AbuseTMJ (Jaw Joint Problems)Tobacco UseAlcohol UseAnesthesia ComplicationsDrug or Substance Allergies
Do you have Hepatitis?*

YesNo
If yes, what type:
Do you have Diabetes?*

YesNo
If yes, what type:
I hereby state that, to the best of my knowledge, the above information is true and accurate, complete to my satisfaction, and that I will not hold the dentist or the staff responsible for any errors or omissions in the completion of this form.
Signature of Patient / Legal Guardian*

Clear
Date*

MonthDayYear
What was your last A1C and when was it taken?
I authorize the release of any information related to my health care or to my claims. I understand that I am financially responsible for the costs related to treatment. I authorize payment of my benefits, otherwise payable to me, directly to EPIC Perio and I authorize the use of the signature on all insurance submissions.
Signature of Patient / Legal Guardian*

Clear
Date*

MonthDayYear
Should be Empty:

Health History