Name_________________________________________________________________Date____________________________
PATIENT’S DENTAL HEALTH

Why have you come to see us today? (e.g. pain, checkup, etc)__________________________________________________________

Previous Dentist______________________________________________Last Visit______________Date of last cleaning_________

Have you had any problems with past dental treatment?______________________________________________________________

Are you nervous about seeing a dentist?     О  Yes!     О  No   If yes, please tell us why:_______________________________________

How often do you brush?____________________________Do you floss?   О  Yes   О  No   How often?_________________________

Please circle each:
Y    N    I clench or grind my teeth in the day or while sleeping		Y    N    My gums feel tender or swollen
Y    N    My gums bleed while brushing or flossing			Y    N    I have problems eating
Y    N    I like my smile						Y    N    I have had orthodontics
Y    N    I prefer tooth-colored fillings					Y    N    I have had a facial or jaw injury
Y    N    I avoid brushing part of my mouth due to pain			Y    N    I want my teeth straighter
								Y    N    I want my teeth whiter
What are your dental priorities?______________________________________________________________________________________
(eg. Appearance, dental health, financial considerations, etc.)	
PATIENT’S MEDICAL HISTORY

I consider my health to be (Please check one):     О Excellent        О  Good         О  Fair        О  Poor
Do you have or have you had any of the following?  Please circle Y for yes or N for no:
1.   Y   N   Heart disease				22. Y   N   Liver Disease				
2.   Y   N   Heart murmur/Mitral Valve Prolapse 	23. Y   N   Jaundice
3.   Y   N   Stroke					24. Y   N   Hepatitis Type _____
4.   Y   N   Congenital Heart Lesions		               25. Y   N   Diabetes
5.   Y   N   Rheumatic Fever			26. Y   N   Excessive Urination and/or Thirst
6.   Y   N   Abnormal Blood Pressure		27. Y   N   Infectious Mononucleosis (“Mono”)
7.   Y   N   Anemia				28. Y   N   Herpes
8.   Y   N   Prolonged Bleeding Disorder		29. Y   N   Arthritis
9.   Y   N   Tuberculosis or Lung Disease		30. Y   N   Sexually Transmitted  Disease	36. Y   N   AIDS/HIV
10. Y   N   Asthma				31. Y   N   Kidney Disease			37. Y   N   Immune Disorder
11. Y   N   Hay Fever				32. Y   N   Tumor or Malignancy		38. Y   N   Hearing Loss
12. Y   N   Sinus Trouble				33. Y   N   Cancer/Chemotherapy		39. Y   N   Fainting Spells
13  Y   N   Epilepsy/Seizures			34. Y   N   Radiation Therapy		40. Y   N   Glaucoma
14. Y   N   Ulcers					35. Y   N   History of Drug Addiction		41. Y   N   Emotional or Nervous Disorders
15. Y   N   Implants/Artificial Joints:  Hip-Knee_______Other____________________			WOMEN:
16. Y   N   I smoke or use chewing tobacco.  If yes, how much per day?  How many years?	42. Y   N   Are you taking birth control?
17. Y   N   I have consumed alcohol within the last 24 hours.					43. Y   N   Are you pregnant?
18. Y   N   I usually take an antibiotic prior to dental treatment.					44. Y   N   Are you nursing?
19. Y   N   Have you ever taken Fen-Phen or Redux?
20. Y   N   I have had major surgery.    Year________Type of operation______________________________________
21. Y   N   Do you have any other medical problem or medical history NOT listed on this form?	
Are you allergic to any of the following:
Please circle Y for yes or N for no   
44. Y   N   Aspirin/Ibuprofen
45. Y   N   Sulfa Drugs/Sulfites/Sulfides
46l Y   N   Penicillin
47. Y   N   Codeine
48. Y   N   Latex, metals, plastics
49. Y   N   Local Anesthetics (Novacaine)
50. Y   N   Nitrous Oxide
51. Y   N   Other______________________________	
Please list all medications you are currently taking:

	
I have read and understand the above questionnaire and have answered all questions truthfully to the best of my ability.  If ever my health or medications change, I will inform you.
I authorize and request that Andrew Choi DDS, Cindy Park DDS and their auxiliaries administer Xrays, treatment, anesthetics and to perform such procedures as deem necessary in the diagnosis and treatment of my case after discussion of the proposed treatment, alternatives and implications.  I understand that the use of anesthetic agents embodies certain risks.

____________________________________________________________________                   Medical health reviewed by:   
Patient                                                                         Date
____________________________________________________________________                  __________________________________
If Patient is a Minor, Parent/Guardian Signature         Date                                                               Doctor Signature                                Date 	

Date___________________________________________	Social Security No____________________________________

Patient_________________________________________	Drivers License No___________________________________

Address________________________________________	Birthdate___________________________________________

City_____________________State______Zip__________	Preferred  Contact

Home Phone____________________________________	    О Home    О Cell    О Work   О  Other_________________

Work Phone_____________________________________	Email Address______________________________________

Cell phone______________________________________	Full time student?___________________________________
									   		 School Name

Referred to us by____________________________________      Physician__________________________________________________

How did you hear about us?___________________________       Phone No_____________________Fax__________________________
 
Do you have any hobbies or interest?____________________      Address___________________________________________________                                      

__________________________________________________     City_______________________State___________Zip______________

    Person to contact for Emergency 

Name_____________________________________________       Relationship____________________________________________

Phone  No_________________________________________     

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT___________________________________________________

Relationship to patient_______________________________________________________________________________

Do  you have dental insurance?      Yes          No
	
RESPONSIBLE PARTY (Primary Insurance)

Name___________________________Birthday___________

Social Security No_______________________________

Occupation__________________________________ __

Employer______________________________________

Business Phone_________________________________

Insurance Company______________________________

Group #________________________________________

Insurance Address_______________________________

City__________________State_____Zip_____________
	   SPOUSE (Secondary Insurance)

Name___________________________Birthday_________	

Social Security No_____________________________

Occupation___________________________________

Employer____________________________________

Business Phone_______________________________

Insurance Company____________________________

Group #______________________________________

Insurance Address_____________________________

City__________________State_____Zip____________