Gavin M. Aaron, DDS, MS   3005 Peters Creek Road Roanoke, VA 24019 Periodontics and Oral Diagnosis   Last Name:  First Name:  Birth Date Mo -Day-Yr:  Height:  Weight:  Marital Status:   Name You Would Like To Be Called:   Patient Social Security #:   Residence Address:   Residence Telephone:   Cellphone*:   Name Of Spouse/Parent:   Emergency Telephone:   Referred By:   Name Of Physician:   Telephone:     General Yes   NO               Has there been any change in your general health during the last year?                 Are you receiving any treatment by any doctor now? Are you taking any medicines now? If yes, list at bottom of page.                 Have you ever had an operation?                 Have you ever had a serious illness?                 Have you ever been hospitalized?                 Has a dentist or physician ever told you that you had a tumor or a cancer?                 Have you ever had radiation or chemo therapy treatments?                 Have you had rheumatic fever, growing pains, or twitching of the limbs?                 Have you had a stroke (apoplexy, CVA)?                 Have you ever had excessive bleeding following extraction of teeth or from a cut?                 Are you allergic or sensitive to any particular medicine (Penicillin - Codeine)? If yes, list at bottom of page.                 Have you ever been told not to take novocaine?                 Do you suffer from frequent or severe headaches?                 Do you have spells of dizziness?                 Have you ever had severe pains of the face or head?                 Do you have hay fever?                 Do you have sinus trouble?                 Have you ever been diagnosed HIV positive?                 Are you or have you ever been addicted to any medications, substances or alcohol?                 Do you use tobacco? If yes, how often?                   Cardiovascular Yes   NO               Has a physician ever said you had heart trouble?                 Have you ever had rheumatic heart disease?                 Have you ever had a heart attack?                 Has a physician ever said your blood pressure was too high or too low?                 Do you get out of breath easily? Do you bruise easily?                 Do you have a heart murmur?                 Do you pre-medicate for dental visits?                   Respiratory Yes   NO               Do you have asthma?                 Have you ever had tuberculosis?       Gastro-Intestinal Yes   NO               Do you suffer from stomach trouble?                 Have you ever had liver trouble?                 Do you have frequent diarrhea?                 Has a physician ever told you that you had ulcers?                 Are there any foods you cannot eat?                 Have you ever had hepatitis?                   Genito-Urinary Yes   NO               Do you have kidney or bladder trouble?                 Have you ever had syphilis?                   Female Yes   NO               Are you currently pregnant?                 Have you reached menopause?                   Endocrine System Yes   NO               Do you have diabetes?                 Has any family member had diabetes?                 Have you ever taken thyroid tablets?                   Nervous System Yes   NO               Have you ever had a nervous breakdown?                 Do you have epilepsy?                 Are you a nervous person?                 Bones And Joints                 Do you have arthritis or rheumatism?                 Do you have any artificial prosthetic joints?                   Dental Yes   NO               Do your gums bleed when you brush your teeth?                 Have you ever seen a periodontist? Do your teeth ever feel sore when you bite on them?                 Do you think your teeth are moving or drifting?                 Do you grind or clinch your teeth when you are nervous or while sleeping?                 Do you feel that an attempt to save your teeth is a waste of time?       Patient's Signature:     Chief Complaint:     Medications taking:     Allergic to: