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Medical History Form
Silc Periodontics
955 N. Plum Grove Ste E
Schaumburg IL 60173
Phone: 1-847-605-0280 Fax: 1-847-605-0288
Patient Information
First Name:
*
Last Name:
*
Birth Date:
The date must be less than or equal to 05/22/2025
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Gender:
Email Address:
Address 1:
Pref. Phone:
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Work
Cell
Address 2:
Home Phone:
City:
Work Phone:
State:
Cell Phone:
Zip:
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Medical History
Medical History
Check [No] for all
Patient First Name
Patient Last Name
When was your last dental hygiene visit?
Who were you referred by?
Who is your general dentist?
What is the reason for your visit?
Have you had any periodontal (gum) treatments?
Yes
No
Do your gums bleed or feel tender or irritated?
Yes
No
Are your teeth sensitive to hot, cold, or pressure?
Yes
No
Have you noticed any loose teeth or a change in your bite?
Yes
No
Does food tend to get caught between your teeth?
Yes
No
Have you been told you need antibiotics prior to dental treatment?
Yes
No
If yes, what do you take for pre-medication?
Do you have & are you wearing removable dental appliances?
Yes
No
Do you clench or grind your teeth while awake or asleep?
Yes
No
Do you experience clicking or popping in your jaws?
Yes
No
Do you currently smoke or have a history of heavy smoking?
Yes
No
If yes, how many per day and for how long?
We are interested in your feelings about the following: How do you feel about losing your teeth?
What would you change about your smile or bite, if you could?
What is your biggest concern about having any dental treatment?
Are you in good health?
Yes
No
Has there been any change in your general health within the last year?
Yes
No
My last physical examination was on:
Are you currently under a physician's care?
Yes
No
If so, what is the condition being treated?
The name and address of my physician
Have you had any serious illness, operation, or been hospitalized in the past 5 years?
Yes
No
If so, what was the illness or problem?
Are you pregnant?
Yes
No
Pharmacy Name
Pharmacy address (include street, city, state, zip code)
Pharmacy Phone Number
Have you ever or are currently taking I.V, Oral, or Injectable Bisphosphonates for bone density (ex. Fosamax, Actonel, Boniva, Aredia, Zometa, Bonefos, or Prolia)?
Yes
No
Are you currently taking any medications?
Yes
No
What Medications are you currently taking?
Are you allergic to or have you reacted adversely to any of the following medications?
Aspirin
Penicillin
Nitrous Oxide
Local Anesthetic
Codeine
Latex Gloves
Erythromycin
Are you taking blood thinners? Please List name of medication.
Other Medication Allergies
Please mark Yes or NO for each of the following which you have had or currently have:
Substance Abuse Problem
Yes
No
Heart Disease
Yes
No
Mitral Valve Prolapse:
Yes
No
Artificial Heart Valve:
Yes
No
Heart Pacemaker:
Yes
No
High Blood Pressure:
Yes
No
Low Blood Pressure:
Yes
No
Heart Murmur:
Yes
No
Rheumatic Fever:
Yes
No
Excessive Bleeding:
Yes
No
Blood Transfusion:
Yes
No
Cancer:
Yes
No
Radiation Treatments:
Yes
No
Chemotherapy:
Yes
No
Artificial Joint:
Yes
No
Epilepsy or Seizures:
Yes
No
AIDS/HIV positive:
Yes
No
Liver Disease:
Yes
No
Psychiatric Care:
Yes
No
Stroke:
Yes
No
Ulcers:
Yes
No
Diabetes:
Yes
No
Sinus Trouble
Yes
No
Thyroid Disease:
Yes
No
Respiratory problems: Emphysema, Bronchitis, Asthma, or COPD?
Yes
No
Fainting Spells/Dizziness:
Yes
No
Kidney Problems:
Yes
No
Hepatitis: A, B, or C?
Yes
NO
Are there any other health conditions that you feel we should know about?
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Clear all medical history selections?
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Medical History
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