Periogreenville.com

Periodontics of Greenville
Date ___________________
Please complete this form in print and bring with you to your next appointment:
Name __________________________________________ Preferred Name “ __________________________________ ”
Social Security # ___________________________________________________________________________________
Date of Birth ________________________ Marital Status _______Height ______ Weight _________Sex ____________
Home Address _____________________________________________________________________________________
City ________________________________ State ___________ Zip _____________ E-mail ______________________
Home ( ______ ) ______- _______________ Mobile ( _____ ) _______ - __________ Work ( _____ ) _____ - _________
Please note: By listing above contact information, you agree for our office to utilize this information to contact
you regarding any communication.
Dental Insurance Company*: _______________________________________________ *Please present card for duplication
Insured’s Employer: _________________________________________________________________________________
Insured’s Name, SSN and DOB (if other than patient): ______________________________________________________
Name and Address of Responsible Party (if other than patient)
Name ____________________________________________________________________________________________
Address __________________________________________________________________________________________
Referred by ________________________________ General Dentist’s Name ___________________________________
Have you, or any family member, ever been a patient of this office? Yes No
If yes, name of family member and relationship to patient ___________________________________________________
Emergency Contact __________________________________________________Phone _________________________
**Please note: By listing a contact person above, you agree for our office to disclose any and all pertinent
information regarding your care to this person in the event of an emergency.
Please describe reason for this visit:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Patient Medical History
General Physician ____________________________ Phone ___________________Date of last exam ____________
1. Are you under the care of another physician?.Yes No
If Yes, Why? ___________________________________________________________________________________________ 2. Have you ever been hospitalized for any surgical operation or serious illness? .Yes No
If Yes, When? __________________________________________________________________________________________ 3. Have you been in any other institution (weight reduction, drug or alcohol treatment, mental, psychiatric, or other) in the last three Explain _______________________________________________________________________________________________
4. Are you taking any medications or supplements? .Yes No
If yes, What? ___________________________________________________________________________________________
5. Please circle any of the following medications for Osteoporosis you have taken in the last 12 months:
Fosamax Boniva Actonel Zometa Aredia Bonefos Didronel Other: _______________ 6. Are you currently taking any blood thinners (this includes Plavix, Aspirin, Coumadin)? .Yes No
If yes, What? ___________________________________________________________________________________________
Please turn page over and continue
7. Have you ever been instructed by a doctor to pre-medicate with antibiotics prior to going to the dentist due to a joint
replacement or a heart condition? .Yes No 8. Are you currently using tobacco products?.Yes No
9. Do you drink alcohol? .Yes No
10. Do you use recreational drugs? .Yes No
11. Are you allergic to any drugs or medicine (including anesthesia)?.Yes No
If yes, which one(s)? _____________________________________________________________________________________
12. Are you allergic to latex or any rubber products? .Yes No
13. Are you allergic to milk, eggs, or any other food products? .Yes No
If yes, which one(s)? _____________________________________________________________________________________
14 Women only
a. Are you pregnant or think you may be pregnant? .Yes No
b. Are you nursing? .Yes No
c. Are you taking birth control pills, hormones or using female contraceptives? .Yes No
Do you have or have you had any of the following?
Cardiovascular
Endocrine
Cancer / Blood Disorders
Radiation Therapy or Chemotherapy . Yes No Respiratory
Stomach / Intestinal Problems
Chronic Obstructive Pulmonary Disease . Yes No Neurologic
Transient Ischemic Attacks (TIAs) . Yes No Joint Replacement / Joint Implants. Yes No Infectious Disease / Immune Problems
Any Adverse Reactions to Anesthesia . Yes No Infectious / Sexually Transmitted Disease . Yes No Other condition(s) not mentioned above ____________________ **If you are a regular blood donor, please check with your blood donation center regarding their guidelines for
donation after receiving bone grafting**
Authorization and Release
I certify that I have read and understand the above information and, to the best of my knowledge, all questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependent during the period of such Dental care to third party payers and/or health practitioners.
x _________________________________________________________________________________________________________

Source: http://www.periogreenville.com/downloads/Health-History.pdf