Periodontal Disease History Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Dental History
Have you previously been diagnosed with periodontal (gum) disease?
Yes
No
If yes, age at diagnosis
What treatment(s) have you received?
How often do you visit the dentist?
Every 6 months
Yearly
Only when needed
Symptoms
Do you currently experience any of the following? (Select all that apply)
Bleeding gums
Swollen or tender gums
Loose teeth
Persistent bad breath
Receding gums
None
Medical History
List any medications you are currently taking
Do you have any of the following?
Diabetes
Heart Disease
Smoker
Pregnancy
Other
Additional Relevant Information