* Marks a required field
Full Name *
Email Address *
Residential Telephone *
1. Are you in good health? *
2. Are you being treated by a physician now? *
3. Are you taking any drugs of medication? *
If yes, please list your drugs or medications
4. Have you had excessive bleeding requiring special treatment? *
5. Have you had surgery within the last 5 years? *
6. Have you ever been treated for a tumor or skin disease? *
7. Have you ever had any of the following conditions?
(Select all that apply)
Rheumatic FeverHeart DiseaseStrokeHigh or Low Blood PressureBlood DiseaseAnemiaDiabetesLiver Disorder (Hep A, B or C)Kidney Disorder
Respiratory DisorderAidsAre you HIV positiveArthritisAsthmaStomach DisorderIntestinal DisorderOther
8. Has anyone in your family ever had diabetes? If yes, who? *
9. Are you allergic to any of the following drugs?
Local Anesthetic (Novacaine)PenicillinOther antibiotics
AspirinBarbituates, Sedatives, Sleeping pillsOther Drugs
If you've selected "Other Drugs", please specify
10. Do you smoke? If yes, how many? *
11. Have you ever had periodontal treatment? *
12. Have you ever had orthodontic treatment? *
13. Do you clench or grind your teeth? *
14. For women, are you pregnant?
15. Have you reached menopause?
16. Is there anything else is your health history that we should know?
Periodontal disease is produced by a combination of many complex elements.
Although some of the following questions may seem unrelated to your gum condition, they are all associated with proper management of your oral health.