Comprehensive Periodontal Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Address: _________________ Phone: _________________
• Emergency Contact: _________________ Phone: _________________

Dental History

• Last dental visit: ________________
• Reason for today's visit: ________________
• Previous periodontal treatment? □ Yes □ No
• Bleeding gums while brushing/flossing? □ Yes □ No
• Loose teeth or change in bite? □ Yes □ No
• Sensitivity to hot/cold? □ Yes □ No

Medical History

Current Medical Conditions (check all that apply)

□ Heart Disease □ Diabetes □ High Blood Pressure □ Arthritis □ Bleeding Disorders □ Osteoporosis □ Cancer □ HIV/AIDS □ Hepatitis

Medications

• Current medications: ________________
• Anticoagulants/blood thinners? □ Yes □ No
• Bisphosphonates for osteoporosis? □ Yes □ No

Allergies

□ Local Anesthetics □ Penicillin □ Latex □ Other: ________________

Social History

• Tobacco use: □ Never □ Former □ Current
• Alcohol consumption: □ Never □ Occasional □ Regular

Women Only

• Pregnant? □ Yes □ No
• Nursing? □ Yes □ No

Certification

I certify that the above information is complete and accurate.

Signature: _________________ Date: _________

Doctor's Notes: _________________