Health History | O'Neal Periodontics, PC

A. Cheria O'Neal, DMD, MHS 1225 Johnson Ferry Rd, Suite 760 Marietta, GA 30068 Call 770.971.5375

Health History

*indicates response required

*Patient Name:

Date of Birth:

Occupation:

General Dentist:

Physician's Name:

Physician's Phone:

Physician's Address:

Date of last medical visit:

Have you had periodontal disease in the past?

Yes No

Have you been told to take antibiotics before dental treatment?

Yes No

Have you been hospitalized in the last 5 years? If so, please explain:

Are you presently being treated for any illness or medical condition? If so, please list (or provide a list):

Do you currently have, or have you ever had:

What drugs/medications do you take or have you taken in the past year? (Please list medications and dosage on next page.)

Are you allergic to or have you reacted adversely to the following:

No Allergies

Local Anesthetics (Novocaine)

Aspirin or ibuprofen

Barbiturates, sedatives, or sleeping pills

Penicillin, tetracycline, sulfa drugs or other

Please list:

Codeine or other narcotics

Nitrous oxide (laughing gas)

Latex

Allergies to other medications

Please list:

Do you have any condition, problem or disease not mentioned above? If yes, please explain:

Women: Are you pregnant?

Yes No

Taking birth control pills?

Yes No

Your comments or concerns:

*Signature of Patient:

Date:

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