Keith E Vaughan DDS

Keith E Vaughan DDS

6521 George Washington Memorial

Highway, Yorktown VA 23692, USA P.O. Box 1207

smiles@vaughan.hrcoxmail.com

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Contact & New Patient Form

Medical Hx and Dental Hx Duplex

Medical Hx and Dental Hx Duplex

Medical History

Contact Us

Patient Name

Patient Account No.

Medical Alert

1. Primary Care Physician’s name

Phone

Last Physical Examination

2. Other Physician’s Name

Phone

3. Are you taking any medication, drugs or pills now, including regular dosages of aspirin?

Yes

No

If yes, please list name and dosage

4. Have you had a recent onset of respiratory problems like cough or difficulty breathing?

Yes

No

5. Are you aware of an allergic (adverse) reaction to any medication or substance?

Yes

No

If yes, please list:

Have you been a patient in the hospital during the past five years?

Yes

No

Free Text

7. Indicate which of the following you have had, or have at present. Circle “Yes” or “No” to each item.

Heart (Surgery, Disease, Attack)

Yes

No

Chest Pain

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Radiation Therapy

Yes

No

Thyroid Disease

Yes

No

Heart Murmur/MVP

Yes

No

High Blood Pressure

Yes

No

Artificial Heart Valve

Yes

No

Heart Pacemaker

Yes

No

Rheumatic Fever

Yes

No

Arthritis/Rheumatism

Yes

No

Cortisone Medicine

Yes

No

Swollen Ankles

Yes

No

Stroke

Yes

No

Diet (Special/Restricted)

Yes

No

Artificial Joint (Hip, knee, etc)

Yes

No

Tobacco

Yes

No

Sleep Apnea

Yes

No

Ulcers

Yes

No

Diabetes

Yes

No

Tumors

Yes

No

Emphysema

Yes

No

Contact Lenses

Yes

No

Chronic Cough

Yes

No

Tuberculosis

Yes

No

Asthma

Yes

No

Hay Fever

Yes

No

Latex Sensitivity

Yes

No

Allergies/Hives

Yes

No

Sinus Trouble

Yes

No

Fainting

Yes

No

Nervous/Anxious

Yes

No

Snore

Yes

No

Kidney Trouble

Yes

No

Hepatitis A (Infectious)

Yes

No

Hepatitis B (Serum)

Yes

No

Hepatitis C

Yes

No

Venereal Disease

Yes

No

A.I.D.S/H.I.V. Positive

Yes

No

Blood Transfusion

Yes

No

Hemophilia

Yes

No

Sickle Cell Disease

Yes

No

Bruise Easily

Yes

No

Liver Disease

Yes

No

Yellow Jaundice

Yes

No

Neurological Disorders

Yes

No

Epilepsy or Seizures

Yes

No

Psychological Care

Yes

No

Psychiatric Care

Yes

No

8. Do you use more than two pillows to sleep?

Yes

No

9. Have you lost or gained more than 10 pounds in the past year?

Yes

No

10. Do you have or have you had any disease, condition, or problem not listed?

Yes

No

If yes, please list:

11. Women, are you pregnant?

Yes

No

Nursing?

Yes

No

Taking birth control pills?

Yes

No

If pregnant, how many months?

12. Have you had eye surgery?

Yes

No

If yes, explain

Free Text

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, which may release such information to you. I will notify the doctor of change in my health or medication.

Patient/Guardian Signature

Date

History Review

Dentist Signature

Date

Free Text

Dental History

Patient Name

Patient Name Patient Account #

Medical Alert

Free Text

Welcome! So that we may provide you with the best possible care,

please complete both sides of this medical/dental history form.

All information is completely confidential.

What is the reason for your visit today?_

Date of last dental visit

last dental cleaning

last full mouth x-rays

What was done at your last dental visit?

Previous Dentist’s Name

Address

State

ZIP

Telephone

How often do you have dental examinations? _

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use (toothpicks, Interplak, etc.)

*Do you have any dental problems now?

Yes

No

If yes, please describe

Free Text

Are any of your teeth sensitive to:

Hot or Cold?

Yes

No

Sweets?

Yes

No

Free Text

Have you ever had:

Orthodontic treatment?

Yes

No

Oral Surgery?

Yes

No

Biting or Chewing?

Yes

No

Have you noticed any mouth odors or bad tastes?

Yes

No

Do you frequently get cold sores blisters or any other oral lesions?

Yes

No

Do your gums bleed or hurt?

Yes

No

Have your parents experienced gum disease or tooth loss?

Yes

No

Have you noticed any loose teeth or change in your bite?

Yes

No

Does food tend to become caught in between your teeth?

Yes

No

If yes, where?

Free Text

Do you:

Clinch or grind your teeth awake or while you sleep?

Yes

No

Bite your lips or cheeks regularly?

Yes

No

Hold foreign objects with your teeth (pencils, nails, pipe?)

Yes

No

Mouth breathe asleep or awake?

Yes

No

Have tired jaws, especially in the AM?

Yes

No

Smoke/chew tobacco?

Yes

No

Periodontal treatment?

Yes

No

Your teeth ground or bite adjusted?

Yes

No

A bite plate or mouth guard?

Yes

No

A serious injury to head/mouth?

Yes

No

If so, please describe, including cause

Free Text

Have you experienced:

Clicking or popping of the jaw?

Yes

No

Pain? (joint, ear, side of face)

Yes

No

Difficulty in opening/closing the mouth?

Yes

No

Difficulty in chewing on either side?

Yes

No

Headaches, neck aches or shoulder aches?

Yes

No

Sore muscles (neck, shoulders)?

Yes

No

Are you happy with your smile?

Yes

No

Would you like to keep all of your teeth all of your life?

Yes

No

Do you feel nervous about having dental treatment?

Yes

No

If so, what is your biggest concern:

Have you ever had an upsetting dental experience?

Yes

No

If yes, please describe:

Is there anything else about having dental treatment that you would like us to know?

Yes

No

If yes, please describe

Free Text

(Please complete the other side)

Keith E Vaughan DDS M/DH Form #18 Revised 7/31/14

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Keith E Vaughan DDS

6521 George Washington Memorial Highway, Yorktown VA 23692, USA P.O. Box 1207

Fax: 757-898-7390

smiles@vaughan.hrcoxmail.com

Hours of Operation:

Mon - Thu: 8:00 am - 5:00 pm
Fri - Sun: Closed

Contact Us

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

Check Payment Accepted

Debit Payment Accepted

Money Order Payment Accepted

Browse Our Website

Home
Dental Care
Dr. Vaughan Bio
About Us
Location
Contact & New Patient Form

Contact Information

Keith E Vaughan DDS

6521 George Washington Memorial Highway, Yorktown VA 23692, USA P.O. Box 1207

Fax: 757-898-7390

smiles@vaughan.hrcoxmail.com

Hours of Operation:

Mon - Thu: 8:00 am - 5:00 pm
Fri - Sun: Closed

Contact Us

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

Check Payment Accepted

Debit Payment Accepted

Money Order Payment Accepted

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