Patient Medical History

1
Patient Medical History
Patients Name
Address Todays 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? Are you
Pregnant? If Yes, of weeks
_______ Are you Nursing?
Yes No
Do you smoke or use tobacco? Height __________
Weight __________
Yes No
Yes No
Yes No
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

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

Taken Fen-Phen Thyroid Problems
Tuberculosis Ulcers
Venereal Disease Yellow
Jaundice
Allergies Aspirin Codeine
Dental Anesthetics Erythromycin
Jewelry Latex
Metals Penicillin
Tetracycline Other
________________________
Yes No
2
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
Signature _____________________________________

Date _______________________
( If under 18, Parent or Guardian Signature
Required)
3
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? _______________________________
___________________________
Doctors 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?

Yes No
4
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?

Are you interested in Laser? Oral
Sedation? Invisalign?
5
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_________________
_________________________________________Doctors
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