Periodontal Patient Medical History Form
Patient Information
First Name
Date of Birth
Last Name
Phone Number
Address
Emergency Contact
Name
Phone
Relationship
Physician Information
Physician's Name
Physician's Phone
Medical Conditions
Heart Disease
Diabetes
High Blood Pressure
Stroke
Epilepsy
Bleeding Tendency
Osteoporosis
Asthma
Other Conditions
Allergies
List any allergies
Medications
List any medications you are currently taking
Lifestyle
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Dental History
Have you had previous periodontal treatment?
Yes
No
Dental Concerns
Women Only
Are you pregnant?
Yes
No
Are you nursing?
Yes
No