Presentation on theme: "Patient Medical History Patient’s Name : Address :Today’s Date : City, State, Zip : Email : Home Phone : Cell Phone : Birth Date : Social Security : Marital."— Presentation transcript:
Patient Medical History Patient’s Name : Address :Today’s Date : City, State, Zip : Home Phone : Cell Phone : Birth Date : Social Security : Marital Status : Yes No If Female Please answer the following: Please answer the following: Yes No Are you taking Birth Control Pills? Are you Pregnant? If Yes, # of weeks _______ Are you Nursing? Yes NoDo you smoke or use tobacco? Height: __________ Weight: __________ Physician Name : Physician Phone: Employer : Work Phone: Allergies Aspirin  Codeine  Dental Anesthetics  Erythromycin  Jewelry  Latex  Metals  Penicillin  Tetracycline  Other ________________________ 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   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  Taken Fen-Phen  Thyroid Problems  Tuberculosis  Ulcers  Venereal Disease  Yellow Jaundice 
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) For Office Use Only BP _______ Heart Rate:________ Medical Alerts :
Dental History 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? __________________________________________________________ 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? Doctor’s Comment: Yes No Referral : Insurance Carrier :
Are you interested in : Laser? Oral Sedation? Invisalign? 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?
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 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 HIPAA Acknowledgement