Medical history



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Jangsook Kim DDS




MEDICAL HISTORY


  1. Have you been under care of a medical doctor during the past two years?

If yes, for what? ________________________ Physician’s Name ____________________________________

Yes

No

  1. Are you taking any medication, drugs or pills, including regular dosages of aspirin?

If yes, please list all within the last 2 years, name and dosage _________________________________________

____________________________________________________________________________________________



Yes

No

  1. Are you aware of having an allergic reaction to any medication or substance?

If yes, please list ______________________________________________________________________________

Yes

No

  1. Have you been a patient in the hospital during the past five years?

If yes, please describe _________________________________________________________________________

Yes

No

  1. Are you pregnant? Yes No Months? ____ Are you breastfeeding? Yes No Taking birth control pills?

Yes

No

  1. Have you ever had any unfavorable reaction to a dental treatment?

If yes, please explain _________________________________________________________________________

Yes

No

Indicate which of the following you have had, or have at present. Circle “yes“ or “no“ to each item











AIDS / HIV

Yes

No

Alcoholism

Yes

No

Allergies or hives

Yes

No

Anemia

Yes

No

Arthritis, rheumatism

Yes

No

Artificial joints

Yes

No

Asthma

Yes

No

Bleeding problems

Yes

No

Blood disease

Yes

No

Bruise easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Chest pain

Yes

No

Chronic cough

Yes

No

Cold sores, fever blisters

Yes

No

Congenital heart disease

Yes

No

Contact lenses

Yes

No

Cortisone Medicine

Yes

No

Diabetes

Yes

No

Emphysema

Yes

No

Epilepsy or seizures

Yes

No

Fainting or dizzy spells

Yes

No

Glaucoma

Yes

No

Hay fever

Yes

No

Headache

Yes

No

Heart attack, surgery

Yes

No

Heart murmur

Yes

No

Hemophilia

Yes

No

Hepatitis A or B

Yes

No

High blood pressure

Yes

No

Kidney disease

Yes

No

Latex allergies

Yes

No

Liver Disease

Yes

No

Low blood pressure

Yes

No

Nervous disorders

Yes

No

Neurological disorders

Yes

No

Osteoporosis

Yes

No

Pacemaker

Yes

No

Penicillin allergies

Yes

No

Phen-fen use

Yes

No

Psychiatric care

Yes

No

Psychological care

Yes

No

Radiation therapy

Yes

No

Rheumatic fever

Yes

No

Sickle cell disease

Yes

No

Sinus trouble

Yes

No

Smoking

Yes

No

Stomach ulcer

Yes

No

Stroke

Yes

No

Swollen ankles

Yes

No

Thyroid problems

Yes

No

TMJ problems

Yes

No

Tuberculosis

Yes

No

Tumors

Yes

No

Ulcers

Yes

No

Venereal Disease

Yes

No

Yellow Jaundice

Yes

No







Do you have or have you had any disease, condition or problem not listed?

If yes, please list _________________________________________________________________________________



Yes

No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication.

______________________________ __________________________ ____________ ________________________

Patient Name Signature Last updated Dentist Signature
Please STOP !! These are for the future to update your medical history yearly.



2ND YEAR MEDICAL HISTORY UPDATE Has there been any change in your health since your last dental appointment?

If yes, please explain…………………………………………………………………………………………………………………



Yes

No

______________________________ __________________________ ____________ ________________________



Patient Name Signature Last updated Dentist Signature


3RD YEAR MEDICAL HISTORY UPDATE Has there been any change in your health since your last dental appointment?

If yes, please explain …………………………………………………………………………………………………………………



Yes

No

______________________________ __________________________ ____________ ________________________



Patient Name Signature Last updated Dentist Signature

937 N. Lemon St Anaheim, CA 92805 23501 Cinema Dr. Suite 114 Valencia, CA 91355


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