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:
YesNo
If so, what medications?
YesNo
If so, what medications?
YesNo
If so, what did you take, for how long and when did you stop?
YesNo
If so, what medications?
YesNo
1st trimester2nd trimester3rd trimester
YesNo
If so, what for?
YesNo
If so, how much and how long have you been smoking or using other forms of tobacco?
YesNo
If so, how much and how often?
Health Information

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

YesNo
Moderna (Both doses)Moderna (Awaiting second dose)Pfizer (Both doses)Pfizer (Awaiting second dose)Johnson & Johnson
YesNo
If so, for what reason?
Date of Last General Physical

MonthDayYear
Date
Physician's Name

First NameLast Name
Physician's Phone Number
Format: (000) 000-0000.
YesNo
If so, what are they?
Patient or Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Should be Empty: