Updated Medical History Updated Medical History Step 1 of 2 – Patient Information 50% Fred R Dahm DDS Eunku Will Chung DDS MSDPatient Information (Confidential)Name* Last First M.I. Preferred Name Home Address* Apt# City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN#* * Male Female Single Married Other Minor Primary Cell Phone*Work#Home#Primary Email address* In case of emergency (name)* relation* Phone#*Name/source of referral/how did you hear about our offices* Person financially responsible:* Phone#*Relationship to patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN#* Primary Dental Insurance InformationDo you have dental Insurance?* Yes No Policy Holder/Subscriber Name:* Relationship to Patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN* ID#* Group#* Dental Insurance Company* (Please provide copy of dental card) Employer* Secondary Dental Insurance InformationDo you have dental Insurance?* Yes No Policy Holder/Subscriber Name:* Relationship to Patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN* ID#* Group#* Dental Insurance Company* (Please provide copy of dental card) Employer* I certify that the above information is true to the best of my knowledge.If any of this information changes,I will provide that information to Fred Dahm DDS as soon as possible.I understand that failure to provide accurate insurance in a timely manner may result in being billed for the full fee for any services provided to me.Signature*Date* MM slash DD slash YYYY Fred R Dahm DDS Eunku Will Chung DDS MSDPatient Medical HistoryPhysician Office Phone#Last Exam MM slash DD slash YYYY Are you under medical treatment now?* Yes No Are you wearing contact lenses?* Yes No Have you ever been hospitalized?* Yes No Are you allergic to or have had reactions to the following?If yes please explain Local anesthetic (ex. Novocaine)* Yes No Are you taking any medications?* Yes No Penicillin or any other antibiotics* Yes No Including non-prescription medication?* Yes No Sulfa drugs* Yes No If yes, what are you taking? Barbiturates* Yes No Have you ever taken Fen-Phen/Redux?* Yes No Sedatives* Yes No Have you ever taken Fosamax,Boniva,Actonel or any cancer medications containing bisphosphonates* Yes No Ibuprofen* Yes No Have you ever used tobacco?* Yes No Aspirin* Yes No Do you use a controlled substance?* Yes No Any metal (e.g. nickel,mercury,etc.)* Yes No Latex rubber* Yes No Other please list : Women Only: Pregnant or trying to get pregnant?* Yes No Taking oral contraceptives?* Yes No Nursing?* Yes No High Blood Pressure* Yes No Stroke* Yes No AIDS/HIV Infection* Yes No Heart Attack* Yes No Diabetes* Yes No Sexually Transmitted Disease* Yes No Heart Disease* Yes No Kidney Disease* Yes No Hay Fever/Allergies* Yes No Heart Murmur* Yes No Liver Disease* Yes No Tuberculosis* Yes No Mitral Valve Prolapse* Yes No Hepatitis/Jaundice* Yes No Thyroid Problem* Yes No Angina* Yes No Recent Weight Loss* Yes No Glaucoma* Yes No Chest Pains* Yes No Emphysema* Yes No Arthritis* Yes No Easily Winded* Yes No Asthma* Yes No Joint Replacement or Implant* Yes No Cardiac Pacemaker* Yes No Respiratory Problems* Yes No Stomach Troubles/Ulcers* Yes No Low Blood Pressure* Yes No Cancer* Yes No Smoker* Yes No Fainting/Seizures* Yes No Radiation Therapy* Yes No Dental Fears* Yes No Rheumatic Fever* Yes No Leukemia* Yes No Mental Disorders* Yes No Epilepsy/Convulsions* Yes No Anemia* Yes No Nervous Disorders* Yes No Patient Dental History Name & office # of previous Dentist Date of last exam MM slash DD slash YYYY Do your gums ever bleed while brushing or flossing* Yes No Do you have frequent headaches* Yes No Do you ever have bad breath or a funny taste in your mouth* Yes No Do you clench or grind your teeth* Yes No Have you ever had scaling & root planing (deep cleaning)* Yes No Do you bite your lips or cheeks frequently* Yes No Are your teeth sensitive to sweet or sour liquids/foods* Yes No Do you feel pain to any of your teeth* Yes No Are your teeth sensitive to hot or cold liquids/foods* Yes No Are any of your teeth loose* Yes No Have you ever had difficult extractions in the past* Yes No Do you have any sores or lumps in or near your mouth* Yes No Any prolonged bleeding after a tooth extraction* Yes No Do you wear dentures or partials* Yes No Have you had any neck or jaw injuries* Yes No Do you have a dry mouth* Yes No Have you ever experienced any of the following problems:Have you put off dental care out of fear* Yes No Clicking* Yes No Would you consider your teeth to be in good health now* Yes No Pain (joint, ear, side of face)* Yes No Do you like your smile* Yes No Difficulty in opening, closing or chewing* Yes No Have you ever had any orthodontic treatment* Yes No ***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 providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my children during the period of such dental care to third party payors and /or health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits for the payment of all services rendered on my behalf or dependents.***Signature of patient (or parent guardian if a minor)*Print Name* Date* MM slash DD slash YYYY File Upload Drop files here or Select files Accepted file types: jpg, gif, png, pdf, xlsx, xls, jpeg, doc, docx, txt, Max. file size: 50 MB.
