Pylant Periodontics - Medical Health Questionnaire

Medical Health Questionnaire
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Please state in your own words why you are coming to see Dr. Pylant:
Are you allergic to any medications?

YesNo
If so, what medications?
Do you take prescription medications?

YesNo
If so, what medications?
Have you ever taken a bisphosphonate (such as Fosamax/Binosto-alendronate, Boniva-ibandronate, Actonel/Ateliva-risedronate, Zometa/Reclast-zoledronate) or received Prolia injections?

YesNo
If so, what did you take, for how long and when did you stop?
Do you take non-prescription medications?

YesNo
If so, what medications?
Are you pregnant?

YesNo
If so, what trimester are you in?

1st trimester2nd trimester3rd trimester
Have you ever had surgery or operations?

YesNo
If so, what for?
Do you smoke or use any other form of tobacco?

YesNo
If so, how much and how long have you been smoking or using other forms of tobacco?
Do you drink alcohol?

YesNo
If so, how much and how often?
Health Information

Check any of the following which you have had or have at present.*

Have you received COVID-19 vaccination?

YesNo
If so, which one?

Moderna (Both doses)Moderna (Awaiting second dose)Pfizer (Both doses)Pfizer (Awaiting second dose)Johnson & Johnson
Are you presently under the care of a physician for any reason?

YesNo
If so, for what reason?
Date of Last General Physical

MonthDayYear
Date
Physician's Name

First NameLast Name
Physician's Phone Number
Do you have any other disease, condition, or medical problems not listed about that you think Dr. Pylant should know about?

YesNo
If so, what are they?
Patient or Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Should be Empty: