Arizona Periodontics

801 N Wilmot Rd

Tucson, AZ 85711

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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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Home
About Us
Periodontal Treatment
Forms
Contact Us
Leave Us a Review on Facebook
Leave Us a Review on Google

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

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

Debit Payment Accepted

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

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

Debit Payment Accepted

Location

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