801 N Wilmot Rd
Suite
B2
Tucson, AZ 85711
520-881-2940
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Health History (English)
HEALTH HISTORY
Name
Date
Physician
Office Phone
Approximate Date of Last Physical Examination?
Are You Under Medical Treatments Now?
Yes
No
Have You Had Any Major Operations in the Last Year?
Yes
No
If So What?
Do You Have Any Drug Allergies, Including Penicillin?
Yes
No
Has A Physician Ever Informed You that You Had:
A Heart Ailment?
High Blood Pressure?
Respiratory Disease?
Diabetes?
Rheumatic Fever?
Rheumatism or Arthritis?
Tumors or Growths?
Any Blood Disease or HIV +?
Any Liver Disease?
Any Kidney Disease?
Any Stomach or Intestinal Disorder?
Any Bleeding or Clotting Disorder?
Yellow Jaundice or Hepatitis?
Are You in General Good Health at this Time?
Yes
No
Are You Taking Any Medication, Aspirin, or Birth Control Pills?
Yes
No
If So What?
Are You Allergic to Any Known Materials Resulting in Hives, Asthma?
Yes
No
If So What?
Have Any Wounds Healed Slowly or Presented Any Other Complications?
Yes
No
Women Are You Pregnant?
Yes
No
Do You Have a History of Fainting?
Yes
No
Have You Ever Had Any Radiation Treatments? If so, when?
Yes
No
Free Text
DENTAL HISTORY
Do You Have Pain in or near Your Ears?
Yes
No
Any Unhealed Injuries or Inflamed Areas in or Around Your Mouth?
Yes
No
Have You Experienced Any Growth or Sore Spots in Your Mouth?
Yes
No
Do You Habitually Clench Your Teeth During the Night or Day?
Ye
No
Do You Have a History of Temporomandibular Disorder (TMD)?
Yes
No
Have You Ever Had a Local Anesthetic?
Yes
No
Any Reactions or Allergic Symptoms to Local Anesthetic?
Yes
No
Prolonged Bleeding Following Extractions?
Yes
No
Do Your Gums Bleed?
Yes
No
Have You Had Instruction on the Correct Method of Brushing Your Teeth and Gums?
Yes
No
Do You Have Any Dental Complaints at the Present Time?
Yes
No
When Was Your Last Set of Full Mouth X-Rays Taken?
Where?
Do You Have a General Dentist?
Yes
No
Name of General Dentist?
Patient Signature
Date
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Periodontal Treatment
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Contact Information
Address: 801 N Wilmot Rd Suite B2 Tucson, AZ 85711
Email:
azperio@protonmail.com
Phone:
520-881-2940
Hours of Operation:
Mon - Thu
8:00 am
-
5:00 pm
Friday
Appointment Only
Sat - Sun
Closed
Location
Contact Information
Address: 801 N Wilmot Rd Suite B2 Tucson, AZ 85711
Email:
azperio@protonmail.com
Phone:
520-881-2940
Hours of Operation:
Mon-Thu 8:00 AM - 5:00 PM
Friday by Appointment Only
Sat-Sun Closed
Location
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