Heartland Periodontics Medical History Form

MEDICAL HISTORY

Patient Name *

Birth Date *

Please select YES or NO to the following medical questions below

Do you require antibiotics before dental treatment?

Y

N

PRE-MED DOSAGE

NAME *

BP:

/

Pulse:

Date:

Initials:

Continued Medical History

Your current physical health is:

Excellent

Good

Fair

Poor

Are you currently under the care of a physician?

Y

N

Please explain

Please list all physicians and their specialty:

Family Physician:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Preferred Pharmacy:

Phone:

List ALL medications you are taking and reason. Include prescription, supplements, and over the counter. (Include any blood thinning herbal medications or supplements such as: Vitamin E, garlic, fish oil, any oils, bilberry, bromelain, cat’s claw, devil’s claw, dong quai, evening primrose, feverfew, ginger (at high doses), ginkgo biloba, grape seed, ginseng, green tea, horse chestnut, and turmeric.)

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature *

Date

Name *

Date *

Dental History

Special Considerations

Office Use Only

Name Validation