Patient Medical History Patients Name Address Todays Date

Patient Medical History Patient’s Name : Address : Today’s 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? Do you smoke or use tobacco? Are you Pregnant? Yes No Height: _____ If Yes, # of weeks _______ Weight: _____ Are you Nursing? Yes No 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 [] [] [] [] [] [] [] [] [] HIV + AIDS Hay Fever High Cholesterol Heart Attack Heart Surgery Hemophilia Hepatitis A [] Hepatitis B High Blood Pressure Kidney Problems [] Disease Liver Low Blood Pressure Mitral Valve Prolapse Pace Maker [] Pneumocystitis [] Psychiatric Problems Radiation Therapy [] Rheumatic Fever [] Seizures Shingles [] Sickle Cell Disease [] Problems Sinus Stroke Yes [] [] [] [] [] [] No [] [] [] [] [] [] Yes Taken Fen-Phen Thyroid Problems Tuberculosis Ulcers Venereal Disease Yellow Jaundice Allergies [] [] [] Yes Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex Metals Penicillin Tetracycline [] [] [] No [] [] [] [] Other ____________

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: For Office Use Only BP _______ Heart Rate: ____ Medical Alerts : Signature: ___________________ ( If under 18, Parent or Guardian Signature Required) Date: ____________

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? _____________________________ Doctor’s 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? • 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? 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? Are you interested in : Laser? Oral Sedation? Invisalign? Yes No

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 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