Nomi Lee D.D.S

101 East Redlands Boulevard, Redlands, California 92373

909-335-3631

PATIENT MEDICAL HISTORY

PATIENT'S NAME
DATE OF BIRTH
Phone
EMAIL

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 THAT YOU WILL BE RECEIVING. THANK YOU FOR ANSWERING THE FOLLOWING QUESTIONS.

ARE YOU IN GOOD HEALTH
HAVE THERE BEEN ANY CHANGES IN YOUR GENERAL HEALTH WITHIN THE PAST YEAR
DATE OF YOUR LAST PHYSICAL EXAM
PHYSICIAN'S NAME
ADDRESS
PHONE NO
ARE YOU NOW UNDER THE CARE OF A PHYSICIAN
HAVE YOU EVER BEEN HOSPITALIZED FOR ANY SURGICAL OPERATION OR SERIOUS ILLNESS
PLEASE EXPLAIN
ARE YOU TAKING ANY MEDICINE(S) INCLUDING NON-PRESCRIPTION MEDICINE
IF YES, WHAT MEDICINE(S) ARE YOU TAKING
HAVE YOU HAD ANY ABNORMAL BLEEDING
DO YOU BRUISE EASILY
HAVE YOU EVER REQUIRED A BLOOD TRANSFUSION
HAVE YOU HAD A RECENT WEIGHT LOSS
HAVE YOU EVER TAKEN FEN-PHEN OR REDUX
DO YOU USE TOBACCO
DO YOU OR HAVE YOU USED CONTROLLED SUBSTANCES
ARE YOU WEARING CONTACT LENSES
DO YOU HAVE ANY DISEASE, CONDITION OR PROBLEM NOT LISTED ABOVE THAT YOU THINK I SHOULD KNOW ABOUT
WOMEN ONLY:
ARE YOU PREGNANT OR THINK YOU MAY BE PREGNANT
ARE YOU NURSING
ARE YOU TAKING BIRTH CONTROL PILLS
ARE YOU ALLERGIC TO OR HAVE YOU HAD REACTIONS TO:
LOCAL ANESTHETICS LIKE NOVOCAINE
PENICILLIN OR OTHER ANTIBIOTICS
SULFA DRUGS
BARBITURATES, SEDATIVES OR SLEEPING PILLS
ASPIRIN
IODINE
ANY METALS (E.G ., NICKEL, MERCURY, ETC.)
LATEX / RUBBER
OTHER (PLEASE LIST)
DO YOU HAVE OR HAEV YOU EVER HAD THE FOLLOWING:
RHEUMATIC HEART DISEASE OR RHEUMATIC FEVER
SCARLET FEVER
HEART DEFECT OR HEART MURMUR
HEART TROUBLE, HEART ATIACK, OR ANGINA
CHEST PAIN
SHORTNESS OF BREATH
PACEMAKER
HEART SURGERY
HIGH/LOW BLOOD PRESSURE
CONGENITAL HEART PROBLEM
SWELLING OF FEET, ANKLES, HANDS
HEPATITIS, JAUNDICE OR LIVER DISEASE
STROKE
SINUS TROUBLE
LUNG OR BREATHING PROBLEMS
ASTHMA OR HAY FEVER
HIVES OR SKIN RASH
FAINTING OR DIZZY SPELLS
DIABETES
AIDS OR HIV INFECTION
THYROID PROBLEMS
ALLERGIES
ARTHRITIS OR RHEUMATISM
JOINT REPLACEMENT OR IMPLANT
STOMACH ULCER
KIDNEY TROUBLE
TUBERCULOSIS
PERSISTENT COUGH
COUGH THAT PRODUCES BLOOD
CHEMOTHERAPY (CANCER, LEUKEMIA)
SEXUALLY TRANSMITIED DISEASE
EPILEPSY OR SEIZURES
ANEMIA
GLAUCOMA
NERVOUSNESS
TONSILLITIS
TUMORS
MENTAL HEALTH CARE
BACK PROBLEMS
CHEMICAL DEPENDENCY
MITRAL VALVE PROLAPSE
CORTISONE TREATMENT
COLD SORES/FEVER BLISTERS
HYPOGLYCEMIA
EATING DISORDERS

PATIENT'S DENTAL HISTORY

PATIENT'S NAME
DATE OF BIRTH
REASON FOR THIS VISIT
WHEN WAS YOUR LAST DENTAL VISIT
WHAT WAS DONE THEN
HOW OFTEN DID YOU VISIT THE DENTIST BEFORE THEN
PREVIOUS DENTIST (NAME AND LOCATION)
HAVE YOU HAD A COMPLETE SERIES OF DENTAL FILMS (X-RAYS) TAKEN WHEN/WHERE
HOW OFTEN DO YOU BRUSH YOUR TEETH
HOW OFTEN DO YOU FLOSS YOUR TEETH
IS YOUR DRINKING WATER FLUORIDATED
DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSING
ARE YOUR TEETH SENSITIVE TO HOT OR COLD LIQUIDS/FOODS
ARE YOUR TEETH SENSITIVE TO SWEET OR SOUR LIQUIDS/FOODS
DO YOU FEEL PAIN TO ANY OF YOUR TEETH
DO YOU HAVE ANY SORES OR LUMPS IN OR NEAR YOUR MOUTH
HAVE YOU HAD ANY HEAD, NECK OR JAW INJURIES
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING PROBLEMS IN YOUR JAW?
CLICKING
PAIN (JOINT, EAR, SIDE OF FACE)
DIFFICULTY IN OPENING OR CLOSING
DIFFICULTY IN CHEWING
DO YOU HAVE FREQUENT HEADACHES
DO YOU CLENCH OR GRIND YOUR TEETH
DO YOU BITE YOUR LIPS OR CHEEKS FREQUENTLY
HAVE YOU NOTICED ANY LOOSENING OF YOUR TEETH
DOES FOOD TEND TO BECOME CAUGHT BETWEEN YOUR TEETH
HAVE YOU EYER HAD PERIODONTAL TREATMENT (GUMS)
EYER WORN A BITE PLATE OR OTHER APPLIANCE
HAVE YOU EYER HAD ANY DIFFICULT EXTRACTIONS IN THE PAST
HAVE YOU EYER HAD ANY PROLONGED BLEEDING FOLLOWING EXTRACTIONS
DO YOU WEAR DENTURES OR PARTIALS
IF YES, DATE OF PLACEMENT
HAVE YOU EYER RECEIVED ORAL HYGIENE INSTRUCTIONS REGARDING THE CARE OF YOUR TEETH AND GUMS
IF YOU COULD CHANGE ANYIHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE?

AUTHORIZATION AND RELEASE

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 THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTIIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.

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DOCTOR'S COMMENTS

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