Dr. Sam F. Khoury

3000 Alamo Drive, Suite 206, Vacaville, California 95687

707-451-1311

Patient Medical History

Patient Name
Age
Date
Home Address
Phone
Email
City
Soc Sec Number
What is your impression of your health?
When was your last physical examination?
PLEASE ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AS POSSIBLE
Are you presently, or have you been under the care of a physician during the past year? For what purpose?
Do you have any medical condition or medical problems? Please explain:
Are you taking any medication or drugs? What are they:
Are you allergic to any medicine or anything? Latex Rubber? What are they:
Have you had a reaction to local anesthetic or intravenous medications?
Please explain
Have you had complications following medical or dental treatment? Please explain
Do you have bleeding problems or blood diseases? Please explain:
Are you pregnant?
Which Month
Do you smoke or use tobacco?
Comments
PLEASE ANSWER YES OR NO TO THE FOLLOWING CONDITIONS WHICH APPLY
Comments:

The information that I have given on this form is the most complete, up to date medical and/or dental facts that are available. If my medical condition changes in any way I will inform Dr. Khoury before further treatment.

Patient Signature

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Medical History Reviewed:

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Date

Followup History Reviewed:

Dr.
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Vital Signs

Pulse
BP
Temp
Comments:

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