Northern Periodontics & Implant Dentistry

Patient Information Form

Please fill out and submit the form below to send your information to our office. We will print your information for our records upon your visit.

Please fill all the required fields (*)

First Name*
Last Name*
Work Phone*
Home Phone*

Address*
City*
State*
Zip*

Date Of Birth*
Social Security #
Email*

Employer
Business Address

Name Of Spouse
Spouse's Employer
Business Address
Business Phone
Dental Insurance (primary)*
Dental Insurance (Secondary)

Name Of Insured*
Social Security #
Relationship to insured*
D.O.B*

Physician
Address
Dentist
Address

Answers to the following questions are for our records and will be considered confidential.

Approximate date of your last examination*:

Yes    No
  Do you consider yourself to be in good health*?
  Are you presently or have you recently been treated by a physician for any                condition*?
Please List:

     Have you ever had a serious illness or operation?*

Please List:

     Have you lost or gained more than 10 pounds in the last year*?
   Do you use tobacco(smoking/chewing)? packs/day*
    Do you take aspirin or aspirin products on a regular basis*?
  Are you now taking any other medicines (drugs, vitamins, pills or herbs)*?

Which?

Are you allergic or have you reacted adversely to any of the following*?

Yes    No
  Local anesthetic* (Novacain)
  Penicillin or any other antibiotic*
  Aspirin*
  Codeine*
  Iodine*
  Sulfa*
  Latex*
  Other*

WOMEN ONLY

  Are you pregnant or nursing?
  Are you taking birth control medication?
  Have you undergone or are you undergoing menopause?

DENTAL HISTORY

Do you or have you had

Yes  No
   Rheumatic Fever*
   Heart Murmur*
   Mitral Value Prolapse*
   Artificial Heart Value*
   Congenital Heart Disease*
   Heart*(surgery, disease, attack)
   Artificial Joints* (hip, knee, etc.)
   Heart Pacemaker*
   Diabetes*
   Hepatitis A(infectious) B (serum)*
   AIDS, ARC, HIV Infection*
   High Blood Pressure*
   Low Blood Pressure*
   Chest Pain*
   Stroke*
   Osteoporosis/Osteopenia*

Yes  No
Radiation Therapy*
Chemotherapy
Tumors*
Arthritis/Rheumatism*
Cortisone Medication*
Diet*(special restriction)
Kidney Trouble*
Ulcers*
Thyroid Condition*
  Glaucoma*
  Emphysema*
  Chronic Cough*
  Tuberculosis* (TB)
  Asthma or Hay fever*
  Sleep Apnea*

Yes  No
  Latex or Metal Sensitivity*
  Allergies or Hives*
  Sinus Trouble*
  Venereal Disease*
  Cold Sores or Fever Blisters*
  Blood Transfusion*
  Hemophilia*
  Bleeding Problems*
  Bruise Easily*
  Liver Disease*
  Neurological Disorders*
  Epilepsy or Seizures*
  Fainting or Dizzy Spells*
  Psychiatric/Psychological Care*
  Frequent Severe Headaches*

How frequently do you visit your dentist?

Last Dental Cleaning

Name of previous dentist

Yes  No
  Do your gums bleed or hurt*?
   Have any of your teeth recently separated, creating a space
             between them*?
   Does food wedge between any of your teeth*?
Where?

Yes  No
  Periodontal treatment*?date:
  Orthodontic treatment*? date:
  Your teeth ground or the bite adjusted*? date:
  A bite splint or mouth guard*?date:
  A serious injury to the mouth or head*?

Please describe

Yes  No
   Would you be greatly disturbed if you had to lose all your natural
             teeth*?
  Clench or grind your teeth while awake or asleep*?
   Did either parent lose all of their natural teeth*?

Why?

   Are you dissatisfied with the appearance of your teeth*?

Why?

Is there anything else about having dental treatment that you
you would like us to know?if so, please describe.

Are any of your teeth sensitive to the following:

Yes  No
  Hot or cold*? If so, Where?
  Sweets*? If so, Where?
  Biting or Chewing*? If so, Where?
  Have you noticed any mouth odors or bad taste*?

Northern Periodontics & Implant Dentistry, PC
(231) 347-2518
2115 M-119
Petoskey, MI 49770
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Northern Periodontics & Implant Dentistry, PC
Vaughan A. McGraw, D.D.S., M.S.
Michael R. Doctor, D.D.S., M.S.
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