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Patient Medical History

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									                                      Patient Medical History
Patient’s Name :

Address :                                                                    Today’s Date :

City, State, Zip :

Email :

Home Phone :                                              Cell Phone :

Birth Date :                                              Social Security :

Marital Status :

Physician Name :                                          Physician Phone:


Employer :                                               Work Phone:

If Female Please answer the following:       Yes No
                                                                  Please answer the following:
Are you taking Birth Control Pills?
                                                                       Do you smoke or use tobacco?     Yes       No
Are you Pregnant?
                                                                       Height: __________
    If Yes, # of weeks _______
                                                                       Weight: __________
Are you Nursing?


                            Yes No                               Yes    No                                Yes    No
                                         HIV + AIDS               []    []
Abnormal Bleeding           []   []      Hay Fever                []    []             Taken Fen-Phen       []   []
Alcohol Abuse               []   []      High Cholesterol         []    []             Thyroid Problems     []   []
Allergies                   []   []      Heart Attack             []    []             Tuberculosis         []   []
Angina Pectoris             []   []      Heart Surgery            []    []             Ulcers               []   []
Arthritis                   []   []      Hemophilia               []    []             Venereal Disease     []   []
Artificial Heart Valve      []   []      Hepatitis A              []    []             Yellow Jaundice      []   []
Asthma                      []   []      Hepatitis B              []    []
Blood Transfusion           []   []      High Blood Pressure      []    []
Cancer – Chemotherapy       []   []      Kidney Problems          []    []             Allergies          Yes    No
Colitis                     []   []      Liver Disease            []    []
Congenital Heart Defect     []   []      Low Blood Pressure       []    []             Aspirin              []   []
Cosmetic Surgery            []   []      Mitral Valve Prolapse    []    []             Codeine              []   []
Diabetes                    []   []      Pace Maker               []    []             Dental Anesthetics   []   []
Difficulty Breathing        []   []      Pneumocystitis           []    []             Erythromycin         []   []
Drug Abuse                  []   []      Psychiatric Problems     []    []             Jewelry              []   []
Emphysema                   []   []      Radiation Therapy        []    []             Latex                []   []
Epilepsy                    []   []      Rheumatic Fever          []    []             Metals               []   []
Fainting Spells             []   []      Seizures                 []    []             Penicillin           []   []
Fever Blisters              []   []      Shingles                 []    []             Tetracycline         []   []
Frequent Headaches          []   []      Sickle Cell Disease      []    []
Glaucoma                    []   []      Sinus Problems           []    []             Other          ________________________
                                         Stroke                   []    []
 Medications:




Is there any disease, condition, or problem that you think this office should know about that is
not covered above? Yes No                If yes, please describe below……




 Notes:




For Office Use Only

 BP _______           Heart Rate:________

 Medical Alerts :




 Signature: _____________________________________                      Date: _______________________
               ( If under 18, Parent or Guardian Signature Required)
                                           Dental History

  Referral :
  Insurance Carrier :
  When was your last dental appointment? What did you have done?
  __________________________________________________________
  How long since your last thorough examination with full mouth x-rays?
  __________________________________________________________
  What prompted you to seek dental care at this time?
  __________________________________________________________




   Doctor’s Comment:




• Are you teeth sensitive to                                                            Yes   No
              Heat?
              Cold?
              Sweets?
              Biting Pressure?
•Does food constantly get stuck between certain teeth in your mouth?

•Do you get frustrated because you always have something to be treated or repaired
when you visit a dentist?

•Are you dissatisfied with your teeth in anyway?

•Are you dissatisfied with the way your teeth look? (ex. Color, shape, spaces, etc.)

•Do you have any fillings that show in your front teeth?

•Do any of your fillings show when you smile?

•If any of your mercury amalgam fillings need replacement, would you prefer to have a
more natural, tooth-colored restoration instead?

•Have you ever had any teeth removed?

•How long have these teeth been missing?____________

•Do your gums bleed when brushing? Or flossing?

•Do you have pain/swelling of gums?
                                                                                Yes   No
•Do you ever avoid any part of the mouth while brushing?

•Have you been instructed regarding proper home care?

•Do you have an unpleasant taste or odor in your mouth?

•Do you frequently snack between meals on sweets or chew gum?

•How often do you brush your teeth?_______________

•How often do you use floss?_____________________

•Do you want to learn to control dental disease and retain your teeth?

•Has the fear of discomfort kept you from regular dental visits?

•Do you feel nervous about having dental treatment?

•Are you deeply concerned about the finances required to return your mouth to
excellent dental health?

•Have you ever had an upsetting experience in the dental office?

•Frequent, heavy snoring?

•Significant daytime drowsiness?

•Have you been told you stop breathing while sleeping?

•Do you gasp at times when waking up?

•Do you feel unrefreshed in the morning?

•Do you have morning headaches

•Are you aware of teeth grinding at night?

•What is your usual bedtime?___________Wake time?____________

•Do you often experience nasal congestion?

•Dou you wear a CPAP? If so, when did you start wearing it?_______________

•Do you have frequent eye infections?
Are you interested in :
Laser?
Oral Sedation?
Invisalign?
      Authorization for Dental Treatment & Release to Insurance

I authorize and give consent to Dr. Cho and her staff to perform dental treatment,
including but not limited to, local anesthesia, analgesia and other such treatment
which may be necessary for the above named patient. I understand that my
photos may be used for teaching or sharing purposes. I also understand that
the use of these agents and some procedures embody a certain risk. I certify that I
have read and understand the above information to the best of my knowledge.
The above questions have been accurately answered. I understand that there is a
charge for missed or broken appointments without 24 Hour notice.

___________________________________________________________
Print Name

X__________________________________________________________
Signature of patient ( or Parent if minor) Date

X__________________________________________________________
Doctor’s Signature                     Date




                          HIPAA Acknowledgement

 Thank you very much for taking time to review how we are carefully using your
 Health information. If you have any questions we want to hear from you. If
 not, we would appreciate very much your acknowledging your review of our
 policy by signing and returning the form.
 We look forward to seeing you again soon!

 ____________________________________________________________
 Patient Signature                        Date

								
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