G. A. Perry, DDS and Associates

G. A. Perry, DDS and Associates

Medical History

Name______Nickname ______DOB ______M/F Date______

Please circle if you have/had:

Bad Breath Head, neck or jaw pain Dry mouth

Blisters on Mouth/Lips Lip or Cheek biting Sensitivity to pressure

Burning sensation on tongue Loose teeth or broken fillings Sensitivity to hot, cold, sweets

Chew on one side of the mouth Mouth Breathing Swollen, bleeding or tender gums

Cigarette, Pipe, Cigar use Orthodontic treatment Growths/sore spots in mouth

Smokeless Tobacco use Nitrous Oxide Food collection between teeth

Periodontal treatment/disease Dental Implants Excessive bleeding

Have you ever had an allergic reaction to any local or general anesthetics? Yes No

Do you have or have you ever had any of the following, please circle:

Acid Reflux Chemotherapy Hemophilia Psychiatric Problems

Alcohol/Drug Abuse Congenital Heart Defect Hepatitis Radiation Treatment

Allergies/Hives Diabetes Type I High Blood Pressure Respiratory Problems

Anemia Diabetes Type II HIV/AIDS Scarlet Fever

Angina (chest pain) Emphysema Implants Sickle Cell Disease

Anorexia/Bulimia Fainting/Seizures/Epilepsy Jaw Problems Sinus Problems

Arthritis/Rheumatism Frequent Headaches Kidney Problems Sleep Apnea

Artificial Joints Glaucoma Leukemia Stent/Shunt

Artificial Valves Heart Disease Liver Problems Thyroid Disease

Asthma Heart Attack/Stroke Lyme Disease Tuberculosis

Cancer/Tumors Heart Surgery/Pacemaker Oral/Genital Herpes Venereal Disease

Do you have any disease or condition not listed above? ______

Do you have any allergies to any medications? Please list: ______

When you walk upstairs/take a walk, do you stop due to pain in your chest or shortness of breath ? Yes No Do your ankles swell during the day? Yes No

Do you wake up from sleep short of breath? Yes No

Have you ever been treated for osteoporosis or any other bone disorder? Yes No

Are you now or have you ever taken Fosamax, Actonel or Boniva? Yes No

WOMEN:

Are you pregnant? Yes No

Are you nursing? Yes No

Are you practicing Birth Control? Yes No

Do you anticipate becoming pregnant? Yes No

Please List any Medications being taken: ______

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in my health or medications, I will inform the dentist or dental staff at my next appointment.

Patient Signature & Date______Doctor Signature & Date______

Emergency Contact Name and Phone Number ______

Physicians Name and Number______Date of Last Exam ______

EMAIL:______

Effective September 2016