Vlahos Medical History Questionnaire

Medical History Questionnaire

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.
Medical Alert?
Date

MonthDayYear
Date
REGISTRATION INFORMATION

This information will enable us to maintain communication with you.
Name

PrefixFirst Nameinitial Last Name
Date of Birth

MonthDayYear
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone:
Format: (000) 000-0000.
Occupation
Who referred you to our office?
IN CASE OF EMERGENCY

This information will enable us to make any essential contacts.
In case of an emergency contact:

First NameLast Name
Emergency contact phone:
Please enter a valid phone number.Format: (000) 000-0000.
Family Physician:

Physician name Last Name
Physician: Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Specialist:

First NameLast Name
Specialist: Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?
If yes, please explain
When was your last medical checkup?
Has there been any change in your general health in the past year? If yes, please explain.
If yes, please explain
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them.
If yes, please list them
Do you have any allergies? If yes, please list them using the categories below:
Medications:
Latex/rubber products:
Other (e.g. hay fever, seasonal/environmental, foods):
Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
If yes, please explain
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
If yes, please explain
Do you have or have you ever had any of the following? Please check.
Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
If yes, please explain
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
Do you identify as a patient with a disability? If yes, please explain.
If yes, please explain
To the best of my knowledge, the above information is correct:
Date

MonthDayYear
Date
Patient/Parent/Guardian Signature:
Internal Use Only
Date

MonthDayYear
Date
Dentist Signature:
Dentist's Notes
Should be Empty:

Medical History Questionnaire

REGISTRATION INFORMATION

IN CASE OF EMERGENCY

MEDICAL HISTORY

To the best of my knowledge, the above information is correct:

Internal Use Only