PBC Perio Dental Health History Form

Patient Health History
Date*

MonthDayYear
Patient Name*

First NameLast Name
Medical History

Please fill out this form as complete as possible.
Physician's Name

First NameLast Name
Phone Number

Area CodePhone Number
Date of last visit

MonthDayYear
Date
Cardiologist's Name

First NameLast Name
Phone Number

Area CodePhone Number
Date of last visit

MonthDayYear
Date
Have you had any serious illnesses or operations?*

YesNo
If yes, describe:
Have you ever had a blood transfusion?*

YesNo
If yes, approximate dates:
WOMEN: Are you pregnant?*

YesNo
If yes, what is your due date?

MonthDayYear
Date
Nursing?*

YesNo
Taking birth control pills?*

YesNo
Have you ever had (Please check all that apply)

Allergies, hay fever sinusitisAnemiaArthritis, rheumatismArtificial Heart ValvesArtificial JointsAsthmaLow Blood PressureTonsillitisTuberculosisScarlet FeverRheumatic FeverBleeding Abnormally with Extractions or SurgeryFish Oil UseChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough, persistent or bloodyLiver DiseaseThyroid ProblemsBack ProblemsGlaucomaRespiratory DiseaseVenereal DiseaseWeight Loss (unexplained)Blood Disease / Clotting DisordersHerpesHigh Blood PressureAny Immune DeficiencyJaundiceKidney DiseaseSwelling of Feet or AnklesEpilepsyFaintingRadiation TreatmentUlcerCancerHemophiliaSmoker / Tobacco UseAspirin UseSinus TroubleSickle Cell AnemiaSkin RashSlow Healing WoundsOsteoporosisStrokeEmphysemaMitral Valve ProlapsePacemakerHead or Neck TumorHeart MurmurHeart ProblemsShortness of BreathCholesterolOn Blood Thinner
Do you have Hepatitis?*

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

YesNo
If yes, what type:
List all medications you are currently taking:
List any allergies to medications:
Dental History
Reason for today's visit
Date of Last Dental Visit

MonthDayYear
Date
General Dentist

First NameLast Name
Date of Last X-Rays

MonthDayYear
Date
Have you ever had (Please check all that apply)

Bad BreathFood Collection Between TeethSensitivity to Cold, Hot, Sweets, or BitingTeeth Grinding / ClenchingGrowths or Sore Spots in your MouthGums Swollen or TenderPeriodontal TreatmentFingernail BitingMouth Pain with BrushingOrthodontic TreatmentNirtrous Oxide (Laughing Gas)Novacaine or other Local AnestheticJaw Pain, Clicking, or PoppingClicking or Popping JawMouth BreathingBleeding GumsBlisters on Lips or MouthBurning Sensation on TongueChew on One Side of MouthDry MouthLip or Cheek Biting
How often do you floss?
How often do you brush?
Have you ever had an allergic reaction or allergic symptoms to Novocaine, local or General Anesthesia?*

YesNo
Authorization & Release
I have read and answered the above questions to the best of my knowledge. I authorize the doctor and his representatives to release all information necessary to assist in securing the payment of my dental benefits. I understand I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of this signature on all insurance claims.
Signature of Patient / Legal Guardian*
Date*

MonthDayYear
Should be Empty:

Patient Health History

Medical History

Dental History

Authorization & Release