Medical History Form | Princeton Periodontics and Implants

Date *

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Business Phone

Social Security No.

Occupation

Place of Employment

Date of Birth

Sex

Male
Female

Marital Status

Closest Relative

Closest Relative Phone

Closest Relative Email *

Closest Relative Cell Phone Number

Name of Spouse

Employed By:

Social Security Number of Spouse

Phone of Spouse

If you are completing this form for another person, what is your relationship to that person?

Whom may we thank for referring you?

Dental Insurance Primary

Member ID:

Group Number:

Insurance Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Dental Insurance Secondary

Dental Insurance Secondary Address

Address Line 1

Address Line 2

City

State

Zip Code

Pharmacy Preference:

Pharmacy Phone Number

For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential. The information you provide on this form is essential and related to the proper dental treatment you receive. Please note that during your visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Current State of Health

Are you currently under the care of a physician?

No
Yes

If so, what is the condition of being treated?

When were you last seen by a physician?

Have you ever, or do you currently use Medical Marijuana?

Yes
No

Have you been vaccinated for COVID-19?

Yes
No

Medical History

1. Do you have or have you had any of the following?

Rheumatic Fever, Rheumatic Heart Disease, Bacterial Endocarditis

No
Yes

Heart Murmur or Mitral Valve Prolapse

No
Yes

Heart Disease or Heart Attack

No
Yes

Artificial Heart Valve?

No
Yes

Irregular Heartbeat (Arrhythmia)

No
Yes

Pacemaker/Defibrillator

No
Yes

High Blood Pressure

No
Yes

Angina (Chest Pains)

No
Yes

Stroke

No
Yes

Artificial Joint(s) - check all that apply

Date(s) Placed:

Have you had any problems with the artificial joint(s), including revisions or infections?

No
Yes

Other Artificial Implants or Devices

No
Yes

Muscle or Joint Disease

No
Yes

Skin Disease

No
Yes

Hepatitis or other Liver Disease

No
Yes

Stomach or Intestinal Disease

No
Yes

Tuberculosis

No
Yes

Asthma or other Lung Disease

No
Yes

Bleeding problem, Anemia, or other Blood Disease

No
Yes

Kidney Disease

No
Yes

Nervous system Disease or Seizures

No
Yes

Diabetes

No
Yes

Thyroid Disease

No
Yes

Immunosupressive Condition (Check all that apply)

2. Do you have any disease, or condition not listed above?

No
Yes

If Yes, please state what condition.

3. Have you ever been hospitalized or had surgery?

No
Yes

Type and Date of Surgery

4. Have you had an allergic reaction to drugs or latex? (Check all that apply)

5. Do you have undiagnosed symptoms?

No
Yes

6. (Women) Are you or could you be pregnant?

No
Yes

6A. (Women) Are you nursing?

No
Yes

6B. (Women) Are you taking birth control pills?

No
Yes

7. Do you have substance abuse problems (active or recovering, drugs, and/or alcohol)?

No
Yes

8. Do you use smokeless tobacco?

No
Yes

9. Do you smoke?

No
Yes

If Yes, how often?

10. Do you regularly take herbal medicines or dietary supplements? Specifically, do you take (check all that apply).

Dental History

1. Do you have regular dental check-ups?

No
Yes

Date of last exam and X-Rays

2. Have you had any trouble associated with previous dental treatment?

No
Yes

If yes, please explain

3. Have you noticed any lumps or sores in your mouth?

No
Yes

4. Do your gums bleed when you brush your teeth?

No
Yes

5. Have you ever injured your face or jaw?

No
Yes

How and when?

6. Do you suffer from pain in the mouth, face, eyes, neck or throat?

No
Yes

7. Are you unhappy with the appearance of your smile?

No
Yes

If yes, please tell us why:

8. Has fear kept you from seeking dental treatment?

No
Yes

9. Are you allergic to metal or dental material?

No
Yes

Type or name of Dental material.

10. Check the types of dental treatment you have experienced:

If you had surgery, please explain what kind of surgery you had.

I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. Please complete the enclosed medication list on last page and then sign below: