Central Texas Perio and Implants

Central Texas Perio and Implants

Kurt E. Delius D.D.S., M.S.

Todays Date:______Referred By:______

Patient Name:______Date of Birth: ______

Medical History: Please circle yes or no for each question.

Are you currently being treated by a physician? Y N Physician’s Name/Number: ______

Are you taking ANY prescription or over the counter medications?

Y N AntibioticsY N Cortisone/Steroids

Y N Medications for High Blood PressureY N Mood Elevators/Antidepressants

Y N Medications for heart conditionsY N Osteoporosis Medication

Y N Anticoagulant/Blood thinnersY N Dietary Supplements like Fish Oil, Vit. E

Y N Aspirin DailyY N Non-prescribed or illegal drugs

List any other medications______

______

Have you ever had an adverse reaction to any of the following:

Y N Aspirin, AdvilY N PenicillinY N Latex

Y N Dental AnestheticsY N Tetracycline

Y N General AnesthesiaY N Sulfa Drugs

Y N Codeine/NarcoticsY N Erythromycin

List any other adverse reactions:______

For Women:

Y N Are you Pregnant?Y N Taking Hormone Medication?

Y N Are you Nursing?Y N Through Menopause?

Y N Are you Taking Birth Control?

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

Y N Heart Disease

Y N High/Low Blood Pressure

Y N Artificial Heart Valves

Y N Heart Murmur

Y N Pace Maker or Defibrillator

Y N Mitral Valve Prolapse

Y N Rheumatic Fever

Y N Stroke

Y N Seasonal Allergies

Y N Asthma

Y N Emphysema, Tuberculosis

Y N Hepatitis or Liver Disease

Y N Kidney Disease, Bladder Disease

Y N Stomach/Intestinal Problems

Y N Thyroid Problems

Y N Diabetes

Y N Prolonged Bleeding

Y N Artificial Joints

Y N Cancer

Y N Chemotherapy

Y N Radiation

Y N Sexually Transmitted Disease

Y N HIV+/AIDS

Y N Epilepsy, Seizures

Do you Smoke? Y / N How much? ______

Any Surgery in the last 5 years? ______

Family History of: Heart Disease Y N High Blood Pressure Y N Diabetes Y N Other ______

Dental History:

Y N Do your gums bleed while brushing/flossingY N Sensitive to Hot or Cold Liquids/Food

Y N Have you ever had an abscessY N Loose or shifting teeth

Y N Had braces/orthodonticsY N Food trapping between teeth

Y N Had Instructions on brushing/flossingY N Frequent bad breath

Y N Had ulcers/blisters in your mouthY N Frequent Headaches

Y N Do you clench/grind you teethY N Sore/Popping of jaw joint

Y N Do you have a fear of dental treatmentY N Have you ever been treated for Periodontal Disease

Consent for Examination / Treatment

I hereby grant authority to the Doctor in charge to perform procedures that are deemed necessary or advisable in my diagnosis and treatment

Patient Signature______Date:______