Patient Information s6

Closest Relative G AYLE &Telephone______W OOD, ______D.D.S. If you are completing this form for another, PERIODONTICS & ORAL IMPLANTS 310 545 7079 what is your relationship to that person? PATIENT INFORMATION ______Your Name- name______Address______OUR MISSION We are the practice of choice for periodontal care. We utilize the latest __ technology to ensure the best outcome for your City ______State treatment. Our professional team provides services in a compassionate way such that you Zip____ know we care. Your comfort and confidence is our number one goal and our patients are treated like Home#______Fax#______family. We are dedicated to providing a top-notch patient experience and we welcome any of your __ family or friends who require quality periodontal Work#______Cell#______care. Today’s Date______Email WELCOME TO OUR Address______Referred by OFFICE Dr.______Reason for PATIENT MEDICAL HISTORY Referral______For the following questions, circle Yes or Date of Birth______Sex M F No. Your answers are for our records only and are CONFIDENTIAL. Height______Weight______Occupation______(1) Are you in good health? Yes No ___ Social Security No. (2) Date of last physical exam? ______Single______Married______Partner____ (3) Have you ever been hospitalized?Yes No ___ Name of (4) Are you now under the care of a physician? Yes Spouse/Partner______No If so, what is the condition being treated? (14) Are you taking any of the following ______medications? __ Yes No Name, Phone # and Address of physician: Antibiotics Yes No ______Anticoagulants (blood thinners) Yes __ No Bone Density Medications Yes ______No __ Medicine for high blood pressure Yes No ______Cortisone (steroids) Yes No __ Tranquilizers Yes No (5) Have you ever had a serious illness or Antihistamines Yes operation? Yes No No Aspirin Yes No (6) Do you require antibiotics prior to Ibuprofen Yes dental treatment? No Yes No Insulin or Diabetes medication Yes Reason? No ______Digitalis or drugs for heart trouble Yes No (7) Are you pregnant? Yes Nitroglycerin No Yes No Due date:______Oral Contraceptive Yes No Hormone Replacement Therapy Yes (8) Alcoholism/Drug dependence? Yes No No Any other prescription or non-prescription (9) Have you taken any recreational drugs medication Yes No in the past year (cocaine, crack, marijuana, IV drugs)? Yes (15)Have you ever taken Fen-Phen or No other similar medications for weight loss? Yes No (10) Do you use tobacco products? Yes If yes, have you ever been diagnosed with No heart valve problems due to this (11) How much do you smoke per day? medication? Yes No ____ How many years have you smoked? ______(16) Are you allergic or have you reacted adversely to: (12) How much alcohol do you drink per Local or general anesthetics Yes day?______per month?______No Penicillin or other antibiotics Yes (13) Have you had abnormal bleeding with No previous extractions or surgery? Yes Please No List:______Barbiturates, sedatives, Valium, codeine, safety. Therefore, I have reviewed this medical or sleeping pills history carefully and have answered these Yes No questions to the best of my knowledge. I Aspirin Yes understand and agree that in the event of No default Iodine of payment for services, I will pay for collection Yes No fees, interest, and attorney fees. Latex Yes ______No __ Other Yes Signature of Patient (or Guardian) Date No ______(17) Are you perimenopausal, or have you __ experienced menopause? Yes Reviewed by Dr. Gayle Wood Date No

(18) Do you have or have you had any of FOR DOCTOR’S USE ONLY the following diseases or problems? Pain (Please circle ‘Y’ for Yes or ‘N’ for No – duration______answer all conditions): Bleeding______Y N Anemia Y N TMJ Disorder __ Y N Herpes Y N Tumors/Growths Brush______Y N Epilepsy Y N Hepatitis/Jaundice __ Y N Seizures Y N Hives/Skin Floss______Rash _ Y N Asthma Y N Cardiac Pacemaker PM Y N Arthritis Y N Stomach Ulcers Interval______Y N Stroke Y N Rheumatic Fever Interval______Y N Depression Y N Thyroid Disease Last PM Y N Hay fever Y N Frequent ______Urination SX Y N Cancer Y N Radiation Treatment ______Y N Diabetes Y N Venereal Function Disease ______Y N Hemophilia Y N Pain in Jaw Joints Esthetics Y N Tuberculosis Y N Artificial Prosthesis ______Y N Dry Mouth Y N Respiratory Disease Dental TX plan Y N Cold sores Y N Difficulty Swallowing Y N Heart Attack Y N Artificial Heart Valves Y N Ankle Swelling Y N High Blood Pressure Y N Sinus Trouble Y N Mitral Valve Prolapse Y N Blood disease Y N Joint/Hip Y N Heart Surgery Replacement Y N Emphysema Y N Excessive/Abnormal Y N Heart failure Bleeding Y N Heart murmur Y N Kidney Trouble/ Y N Fainting Spells Disease Y N Chemotherapy Y N Rheumatic Heart Y N Angina Pectoris Disease Y N Liver Disease Y N A.I.D.S./H.I.V.

I understand that withholding any information about my health could seriously jeopardize my