<p> Patient Health Questionnaire</p><p>Name </p><p>Reason for your visit today:</p><p>Please answer the following questions about your general health. What is your impression of your general health? ______Height ______Weight ______Birthdate ______When was the last time you were examined by a physician? ______Please circle any of the following which you have had or have now:</p><p>Angina pectoris High blood pressure Diabetes Prosthetic Joint: Chest pains Prolonged bleeding Cancer hip Rheumatic fever Anemia Radiation Treatment knee Heart disease Hepatitis Chemotherapy other: Heart murmur Allergies Kidney problems ______Artificial heart valve Ulcer Arthritis Asthma AIDS/HIV positive Psychiatric treatment Tuberculosis Alcoholism Epilepsy/seizures Lung problems Drug use Fainting spells Injury to jaws/face Steroid therapy Operations</p><p>Do you have any diseases/conditions not listed above? Yes/No Please Explain:</p><p>Have you been under a physician’s care within the last year? Yes/No Are you presently taking any medication(s)? Yes/No If yes, please list them. Continue on back of page if necessary ______Have you ever taken Fosamax, Boniva or Actonel? Yes/No If Yes, how many yrs did you take it? ______Are you allergic to any medication?______Yes/No Have you ever had a reaction to a local anesthetic? Yes/No Have you ever had complications from dental treatment? Yes/No Have you ever been told that you were not eligible to give blood? Yes/No Do you use tobacco? If so how much and what type? Yes/No</p><p>Do you use alcohol ______Yes/No Drinks/week ______Are you presently having problems in your mouth or involving your face? Yes/No Please Explain:</p><p>Have you ever had treatment for gum disease? Yes/No Have you ever had TMJ problems (pain, clicking or locking of the jaw)? Yes/No When did you last have your teeth cleaned? ______WOMEN: Are you pregnant Yes/No What trimester? 1 - 2 - 3</p><p>PATIENT’S SIGNATURE: ______DATE: ______</p><p>Date B/P Date ___ B/P ______Date ____ B/P Date ___ B/P ______</p><p>Doctor’s Notes</p><p>Dr. Jon E. Piche, Board Certified Periodontist Yorktown Periodontics Dr. Sayward E. Duggan, Periodontist</p>