DR. YOSHIDA MEDICAL HISTORY FORM

Noreen Yoshida DDS

4305 Scotts Valley Dr. Scotts Valley CA 95066

Patient Name

First NameLast Name
Preferred Name (If Any)
Patient Is
Sex
Marital status

Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Address
Address 2
City, State, Zip
Home Phone
Home Phone NumberFormat: (000) 000-0000.
Work Phone
Work Phone NumberFormat: (000) 000-0000.
Work Phone Extension
Cell Phone
Cell Phone NumberFormat: (000) 000-0000.
Social Security Number
Drivers License Number
Insurance Info:

Address
Address 2
City
State / Zip
Home Phone
Home PhoneFormat: (000) 000-0000.
Work Phone
Work PhoneFormat: (000) 000-0000.
Extension
Cell Phone
Cell PhoneFormat: (000) 000-0000.
Birth Date

MonthDayYear
Age
Soc. Security Number
Drivers License Number
E-Mail
example@example.com
I would like to receive correspondences via e-mail.
Employment Status
Student Status
Medicaid ID
Pref. Dentist
Employer ID
Pref. Pharmacy
Carrier ID
Pref. Hyg.
Additional Comments

Name of Insured
Relationship to Insured
Insured Soc. Sec Number
Insured Birth Date

MonthDayYear

Employer Information

Rows	Information
Employer Name
Address
Address 2
City, State, Zip

Insurance Company Information

Rows	Information
Insurance Company Name
Address
Address 2
City, State, Zip

Remaining Benefits
Remaining Deductions

Name of Insured
Relationship to Insured
Insured Soc. Sec Number
Insured Birth Date

MonthDayYear

Employer Information

Rows	Information
Employer Name
Address
Address 2
City, State, Zip

Insurance Company Information

Rows	Information
Insurance Company Name
Address
Address 2
City, State, Zip

Rem. Benefits
Rem. Deduct

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Patient Name

First NameLast Name
Birth Date

MonthDayYear

Please answer the following. If yes to any of the below, please explain.

Rows	Yes	No
Are you under a physican's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Have you ever taken Fosemax, Boniva, Actoel or any other medications containing bisphosphonates?

If yes to any of the above, please explain. Please also list all medications you are currently taking (prescription and over the counter). Please also list any major surgeries/operations you have had.

Women, are you:

Rows	Yes	No
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Nursing?

Are you allergic to any of the following?

Other

Do you have, or have you had, any of the following?

Rows	Yes	No
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorders
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
High Cholesterol
Osteoporosis

Have you ever had any serious illness not listed above?

Other
Comments

Signature of patient, parent, or guardian
Date

MonthDayYear
Should be Empty: