Transcript Document

Patient Medical History
Patient’s Name :
Today’s Date :
Address :
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?
Are you Pregnant?
Yes
No
Height: __________
If Yes, # of weeks _______
Weight: __________
Are you Nursing?
Yes No
Abnormal Bleeding
Alcohol Abuse
Allergies
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer – Chemotherapy
Colitis
Congenital Heart Defect
Cosmetic Surgery
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
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HIV + AIDS
Hay Fever
High Cholesterol
Heart Attack
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Pneumocystitis
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Yes
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No
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Yes
Taken Fen-Phen
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Allergies
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Yes
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Other
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No
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No
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________________________
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: _____________________________________
( If under 18, Parent or Guardian Signature Required)
Date: _______________________
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
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?
Yes
No
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