www.clairechodds.com - Patient Medical History Form

Patient Medical History
Patient’s Name*

First NameLast Name
Address*
City, State, Zip
Today's Date *

MonthDayYear
Date
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Social Security Number
Gender*
Marital Status
If "Other" Explain*
Number of Family Members
Physician Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Employer
Work Phone Number
Please enter a valid phone number.
Please answer the following
Are you taking Birth Control Pills?*

YesNoN/A
Are you Pregnant?*

YesNoN/A
If Yes, # of weeks *
Are You Nursing?*

YesNoN/A
Do You Smoke or use Tobacco?*

YesNo
Height*
Weight*
Medical Health History
Abnormal Bleeding*

YesNo
Alcohol Abuse*

YesNo
Allergies*

YesNo
Angina Pectoris*

YesNo
Arthritis*

YesNo
Artificial Heart Valve*

YesNo
Asthma*

YesNo
Blood Transfusion*

YesNo
Cancer - Chemotherapy*

YesNo
Colitis*

YesNo
Congenital Heart Defect*

YesNo
Cosmetic Surgery*

YesNo
Diabetes*

YesNo
Difficulty Breathing*

YesNo
Drug Abuse*

YesNo
Emphysema*

YesNo
Epilepsy*

YesNo
Fainting Spells*

YesNo
Fever Blisters*

YesNo
Frequent Headaches*

YesNo
Glaucoma*

YesNo
HIV + AIDS*

YesNo
Hay Fever*

YesNo
High Cholesterol*

YesNo
Heart Disease*

YesNo
Hemophilia*

YesNo
Hepatitis A*

YesNo
Hepatitis B*

YesNo
High Blood Pressure*

YesNo
Kidney Problems*

YesNo
Liver Disease*

YesNo
Low Blood Pressure*

YesNo
Mitral Valve Prolapse*

YesNo
Pace Maker*

YesNo
Pneumocystitis*

YesNo
Psychiatric Problems*

YesNo
Radiation Therapy*

YesNo
Rheumatic Fever*

YesNo
Seizures*

YesNo
Shingles*

YesNo
Sickle Cell Disease*

YesNo
Sinus Problems*

YesNo
Stroke*

YesNo
Taken Bisphosphonate (Fosamax)*

YesNo
Thyroid Problems*

YesNo
Tuberculosis*

YesNo
Ulcers*

YesNo
Venereal Disease*

YesNo
Yellow Jaundice*

YesNo
Allergies
Aspirin*

YesNo
Codeine*

YesNo
Dental Anesthetics*

YesNo
Erythromycin*

YesNo
Jewelry*

YesNo
Metals*

YesNo
Penicillin*

YesNo
Tetracycline*

YesNo
Other*

YesNo
If "Other" Please Explain*
Please List Medications
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
Doctor’s Signature

Clear
Date

MonthDayYear
Date
Notes
Dental History
How did you hear about us?
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?
Are your teeth sensitive to:
Heat?*

YesNo
Cold?*

YesNo
Sweets?*

YesNo
Biting Pressure?*

YesNo
Does food constantly get stuck between certain teeth in your mouth?*

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

YesNo
Are you dissatisfied with your teeth in anyway?*

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

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

YesNo
Do any of your fillings show when you smile?*

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

YesNo
Have you ever had any teeth removed?*

YesNo
How long have these teeth been missing? *
Do your gums bleed when brushing? Or flossing?*

YesNo
Do you have pain/swelling of gums?*

YesNo
Do you ever avoid any part of the mouth while brushing?*

YesNo
Have you been instructed regarding proper home care?*

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

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

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

YesNo
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?*

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

YesNo
Do you feel nervous about having dental treatment?*

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

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

YesNo
Frequent, heavy snoring?*

YesNo
Significant daytime drowsiness?*

YesNo
Have you been told you stop breathing while sleeping?*

YesNo
Do you gasp at times when waking up?*

YesNo
Do you feel unrefreshed in the morning?*

YesNo
Do you have morning headaches*

YesNo
Are you aware of teeth grinding at night?*

YesNo
What is your usual bedtime?*
Wake time?*
Do you often experience nasal congestion?*

YesNo
Do you wear a CPAP?*

YesNo
If so, when did you start wearing it?*
Do you have frequent eye infections?*

YesNo
Are you interested in : Laser?*

YesNo
Are you interested in : Oral Sedation?*

YesNo
Are you interested in : Invisalign?*

YesNo
Authorization for Dental Treatment and 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 understood 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 48 Hour notice.
Print Name*

First NameLast Name
Signature of patient (or Parent if minor) *

Clear
Date*

MonthDayYear
Date
HIPAA Acknowledgement
Thank you very much for taking the 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!
Name*

First NameLast Name
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Medical History

Please answer the following

Medical Health History

Allergies

Dental History

Are your teeth sensitive to:

Authorization for Dental Treatment and Release to Insurance

HIPAA Acknowledgement