KIMCHE COSMETIC AND SPORTS DENTISTRY PATIENT MEDICAL HISTORY
PATIENT NAME:
DATE:
FAMILY PHYSICIAN:
ANY SPECIALIST?:
Do we have your permission to contact your personal physician if the need arises?
Yes
No
Are you currently under a Medical Doctors care for a physical condition? Yes
Please explain:
No
Pharmacy #:
List All Medications: Non-Prescription & Prescription
Allergies:
Y N
Aspirin
Codeine
Dental
Anesthetics
Y N
Erythromycin
Jewelry
Latex
Y N
Metals
Penicillin
 Tetracycline
Other:
For Women Only:
Miscellaneous:
Height:

’
”
Weight:
Have you lost/gained more than 10 lbs. in the past year?
Y N
 
Are you taking birth control?
 
Are you pregnant? # of weeks
 
Are you nursing?
Office Use: BP
/
Heart Rate:
Conditions: Please check Yes or No to the Following
Y N
Y N
B/4 Dental Appts Abnormal
Do You Premedicate?
Bleeding
Heart
Anemia/Blood
Problems
Disease
Heart
High Blood
Attack
Pressure
Heart
 Artificial
Murmur
Joint
Chest Pain
 Hepatitis A
Artificial
Heart Valve
Mitral Valve
Prolapse
 Rheumatic
Fever
 Hemophilia
 Hepatitis B
Coumadin
Y N
Herpes
(Any Kind)
Fever Blisters/
Cold Sores
Shingles
Pneumocystis
Sinus Problems
Ulcers/Colitis
Malignant
Hyperthermia
Kidney
Problems
High
Cancer
Sleep Apnea/
Stroke
Diabetes
Tuberculosis
HIV+ AIDS
Y N
Hay Fever
 Frequent
Headaches
Thyroid
Problems
Cholesterol
Alcohol/Drug
Abuse
Psychiatric/
Emotional Care
Respiratory
Problems
Asthma
Hepatitis C
Y N
Emphysema
Radiation/
Chemotherapy
Epilepsy/
Seizures
Liver Disease
Tonsils/
Adenoids Removed
Eye/Ear
Disorder
Excessive Snoring
 TMJ/TMD
Problems
Arthritis/
Rheumatism
  Venereal
Disease
  Fainting/
Dizzy Spells
  Do You Take
Herbs/Vitamins?
I attest these answers to be truthful and as complete as possible.
Signature:_____________________________Date: __________Dentist Signature__________________________
PLEASE COMPLETE THE BACK OF THIS FORM
KIMCHE COSMETIC AND SPORTS DENTISTRY
DENTAL INFORMATION
NAME:
DATE:
CIRCLE ANY OF THE FOLLOWING CONDITIONS WHICH YOU HAVE NOW OR MAY HAVE HAD IN THE PAST:
Bleeding Gums
Swelling or Lumps in Mouth
Clenching or Grinding Teeth
Blisters/Sores on Lips or Mouth
Bad Breath
Periodontal Treatment
Orthodontic Treatment
Mouth Breathing
Oral Habits, e.g. fingernail biting
Unfavorable Dental Experience
Extensive Crown and Bridge-work
Complications from Oral Surgery
Pain or Unusual sounds in Jaw, Joints, or Ear
CIRCLE ANY OF THE FOLLOWING THAT YOU USE:
Cigarettes, pipe, cigars
Chewing tobacco
Pop and/or Juice intake
per day
Dental Floss
x/week
Water Jet Device
per day
Fluoride Supplements or Rinse
Brush your teeth
x/day
At present, do you have any dental concerns?
Have you experienced trauma to the jaw? No
(Explain)
Yes
Have you had orthodontic treatment (braces)? No
Yes
Year
How long do you expect to keep your teeth?
What prompted you to seek dental care at this time?
Is there anything in your past dental history I should know about? No
Yes
(Explain)
Are you satisfied with your past dental care?
Date of last teeth cleaning:
Date of last dental x-rays:
Do you like the way your teeth look when you smile? No
Yes
Do you like the color of your teeth? No____ Yes____
What would you change about your smile if you answered “No” to the above question/s?
Are you interested in learning how to enhance your smile through shaping, veneers, bonding, bleaching, orthodontics
(Invisalign)? No___ Yes___
Are you aware our office offers an at-home bleaching system and how it can make a difference in your smile?
No
Yes____
Have you ever had Botox or Dermal Fillers? No_____ Yes_____