4455 E. Camelback Road, Suite #E-100, Phoenix, AZ 85018
Call Us: (480) 504-0506 Schedule Appointment
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Medical History Form

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready and completed for you when you arrive. If you have not scheduled your appointment yet, you may use our online appointment request form or give us a call. Required fields are marked with asterisks (*).

 

Patient Information

First Name: *

Last Name: *

Street Address:

City:

State:

ZIP:

Email Address:

Phone

Employer

Occupation

Address:

City:

State:

Zip

Phone

Spouse Information

First Name: *

Last Name: *

Street Address:

City:

State:

Zip:

Email Address:

Phone

Occupation

Employer

Address:

City:

State:

Zip

Phone

Insurance Information

Social Security Number:

Insurance Company

Policy Number:

Policy Holder's Name

Secondary Insurance Co.

Policy Number:

Policy Holder's Name

Family Dentist

How Long?

Present Dental Complaints:

Have you ever been treated for periodontal disease?

Yes No  

Date

 

Dr.

 

Do you think your teeth are affecting your general health in any way?

What are your reasons for seeking periodontal care?

Are you unhappy with your teeth in any way?

What do you consider to be the state of your general health?

Excellent Good Fair Poor  

Has there been any major change in your general health in the last year?

Date of last physical exam?

Are you under your physician's care now?

Yes No  

Reasons:

Physician(s)

 

Last Visit Date

 

Findings

 

1)

 

 

 

2)

 

 

 

List all medications you are currently taking:

Do you or have you had an allergic reaction to any medications or non-medications? Please list below:

Medications:

Asprin

Tylenol

Dental Anesthetics

 

Percodan

Codeine

Tetracycline

Erythromycin

 

Iodine

Valium

Penicillin

Cortisone

 

Sulfa

Demerol

Fluoride

Barbiturates

 

Other Medications:

Non-medications:

 
 
 

Medical History

Have You Had or Do You Currently Have:

Rheumatic Fever

Yes No  

 

Contact Lenses

Yes No  

 

Blood Disorders

Yes No  

 

Heart Murmur

Yes No  

 

Cancers/Tumors

Yes No  

 

Osteoporosis/Osteopenia

Yes No  

 

Congenital Heart Defect

Yes No  

 

Radiation Treatment

Yes No  

 

Organ Transplant

Yes No  

 

Pacemaker

Yes No  

 

Chemotherapy

Yes No  

 

Hospitalized

Yes No  

 

Heart Trouble

Yes No  

 

Arthritis

Yes No  

 

Fainting Spells

Yes No  

 

Surgery

Yes No  

 

Heart Attack

Yes No  

 

Artificial Joints/Implants

Yes No  

 

Numbness/Tingling

Yes No  

 

Chest Pains (Angina)

Yes No  

 

Physical Limitations

Yes No  

 

Neurological Disorders

Yes No  

 

Arteriosclerosis

Yes No  

 

Thyroid Disease

Yes No  

 

Epilepsy (Seizures)

Yes No  

 

Mitral Valve Prolapse

Yes No  

 

Parathyroid Disease

Yes No  

 

Psychiatric Treatment

Yes No  

 

High Blood Pressure

Yes No  

 

Diabetes

Yes No  

 

Chemical Dependency

Yes No  

 

Heart Surgery

Yes No  

 

Hives

Yes No  

 

Herpes

Yes No  

 

Stroke

Yes No  

 

Allergies

Yes No  

 

AIDS

Yes No  

 

Shortness of Breath

Yes No  

 

Drug Reactions

Yes No  

 

HIV+

Yes No  

 

Emphysema

Yes No  

 

Frequent Headaches

Yes No  

 

Venereal Disease

Yes No  

 

Asthma/Hay Fever

Yes No  

 

Sinus Trouble

Yes No  

 

Steroid Treatment

Yes No  

 

Lung Surgery

Yes No  

 

Kidney Problems

Yes No  

 

Tuberculosis

Yes No  

 

Valley Fever

Yes No  

 

Orthodontic Treatment

Yes No  

 

Ulcers

Yes No  

 

Prostate Disorder

Yes No  

 

Cortisone

Yes No  

 

Bruise Easily

Yes No  

 

Anemia

Yes No  

 

Liver Disease

Yes No  

 

Blood Thinners

Yes No  

 

Jaundice

Yes No  

 

Hemophilia

Yes No  

 

Blood Transfusion

Yes No  

 

Hepatitis

Yes No  

 

Glaucoma

Yes No  

 
 

 

Antibiotics before dental treatment?

Yes No  

Do you consider yourself a nervous person?

Yes No  

Other Medical Conditions:

WOMEN ONLY - Are you currently:

Pregnant

 

Are your menstrual cycles regular?

 

Nursing

 

Are you taking birth control pills, estrogen, or other hormonal supplements?

 

Have you reached menopause?

 
 

 

Are You Having:

Difficulty Chewing

Yes No  

Tooth Sensitivity: Hot, Cold, Sweets

Yes No  

 

Loose Teeth

Yes No  

Changing Bite

Yes No  

Pain in Teeth or Gums

Yes No  

 

Receding Gums

Yes No  

Numbness in Jaw

Yes No  

Bad Taste in Your Mouth

Yes No  

 

Shifting Teeth

Yes No  

Bleeding Gums

Yes No  

Grind or Clench Your Teeth?

Yes No  

 

If you are missing teeth, wearing dentures, or have removable artificial teeth, would you be interested in learning if you qualify for dental implants for permanent tooth (teeth) replacement?

Yes No  

Is there any other medical information not listed which would be important or of benefit in helping us take better care of you?

 

I certify the information recorded on this medical & dental form is correct. I understand it is my responsibility to notify Implant and Periodontal Wellness Center of AZ of any changes. I understand if I withhold information regarding allergies, medical conditions, medications, or supplements I agree not to hold Implant and Periodontal Wellness Center of AZ or its employees liable in the event of death or injury. I understand I am financially responsible for all services rendered regardless of my insurance coverage.

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
Office Hours
Monday8–5
Tuesday8–5
Wednesday7–4
Thursday8–5
Friday8–12
Closed for Lunch12–1
Contact Us
4455 E. Camelback Road
Suite #E-100
Phoenix, AZ 85018
(480) 504-0506
Copyright © 2017-2023 Implant and Periodontal Wellness Center of Arizona and WEO Media (Touchpoint Communications LLC). All rights reserved.  Sitemap
Periodontist Phoenix, AZ - About Us - Implant and Periodontal Wellness Center of Arizona
At Implant and Periodontal Wellness Center AZ, our team offers high-quality and affordable treatment options for patients with oral health problems. Call us today!
Implant and Periodontal Wellness Center of Arizona, 4455 E. Camelback Rd #E-100, Phoenix, AZ 85018 \ (480) 504-0506 \ azimplantsolutions.com \ 12/8/2023 \ Page Keywords: Periodontist Phoenix AZ \