809 Sylvan Ave., Suite 300 • Modesto, CA 95350
(209) 572-6008 Fax: (209) 572-6009
www.centralvalleyperio.com
HEALTH HISTORY

Our primary goal is patient safety, and although our dental personnel primarly treat the area in and around your mouth, your mouth is a part of your entire body.

Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.

 YES     NO
 YES     NO
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 YES     NO
 YES     NO
 YES     NO
 YES     NO
 YES     NO
 YES     NO

WOMEN, please check all that applies:

Pregnant/Trying to get pregnant
Nursing
Using oral contraceptives

Check if you are allergic to any of the following:

Aspirin
Metal/Nickel
Penicilin/Amoxicilin
Latex
Codeine/Hydrocodone
Sulfa Drugs
Acrylic
Local Anesthetics

Do you have, or have had, any of the following?

 YES    NO
AIDS/HIV Positive
 YES    NO
Alzheimer's Disease
 YES    NO
Anaphylaxis
 YES    NO
Anemia
 YES    NO
Angina
 YES    NO
Arthritis
 YES    NO
Artificial Heart Valve
 YES    NO
Artificial Joint
 YES    NO
Asthma
 YES    NO
Blood Disease
 YES    NO
Blood Transfusion
 YES    NO
Breathing Problems
 YES    NO
Bruise Easily
 YES    NO
Cancer
 YES    NO
Chemotherapy
 YES    NO
Chest Pains
 YES    NO
Chronic Sinus Trouble
 YES    NO
Cold Sores/Fever Blisters
 YES    NO
Congenital Heart Disorders
 YES    NO
Congestive Heart Failure
 YES    NO
Cortisone Medication
 YES    NO
Diabetes - Type 1
 YES    NO
Diabetes - Type 2
 YES    NO
Drug Addiction
 YES    NO
Easily Winded
 YES    NO
Emphysema/COPD
 YES    NO
Epilepsy or Seizures
 YES    NO
Excessive Bleeding
 YES    NO
Fainting Spells/Dizziness
 YES    NO
Frequent Cough
 YES    NO
Frequent Headaches
 YES    NO
Gastric or Intestinal Ulcer
 YES    NO
Glaucoma
 YES    NO
Gout
 YES    NO
Hay Fever
 YES    NO
Heart Attack / Failure
 YES    NO
Heart Disease
 YES    NO
Heart Murmur
 YES    NO
Heart Pacemaker
 YES    NO
Hemophilia
 YES    NO
Hepatitis A
 YES    NO
Hepatitis B
 YES    NO
Hepatitis C
 YES    NO
High Blood Pressure
 YES    NO
High Cholesterol
 YES    NO
Hives or Rash
 YES    NO
Hypoglycemia
 YES    NO
Irregular Heartbeat
 YES    NO
Kidney Disease
 YES    NO
Leukemia/Lymphoma
 YES    NO
Liver Disease
 YES    NO
Low Blood Pressure
 YES    NO
Lung Disease
 YES    NO
Mitral Valve Proplapse
 YES    NO
Osteoporosis/Osteoperia
 YES    NO
Pain in Jaw Joints
 YES    NO
Parathyroid Disease
 YES    NO
Psychiatric Care
 YES    NO
Radiation Therapy
 YES    NO
Recent Weight Loss
 YES    NO
Renal Dialysis
 YES    NO
Rheumatic Fever
 YES    NO
Rheumatoid Arthritis
 YES    NO
Scarlet Fever
 YES    NO
Shingles
 YES    NO
Sickle Cell Disease
 YES    NO
Sleep Apnea
 YES    NO
Spina Bifida
 YES    NO
Stomach / Intestinal Disease
 YES    NO
Stroke
 YES    NO
Swelling of Limbs
 YES    NO
Thyroid Disease
 YES    NO
TIA (mini-stroke)
 YES    NO
Tuberculosis
 YES    NO
Tumors of Growths
 YES     NO
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in my medical status of medications.