DR. YOSHIDA MEDICAL HISTORY

Noreen Yoshida D.D.S.

108 Whispering Pines Dr. #225

Scotts Valley, CA 95066

831-438-8706

Basic Patient Information
Patient Name

First NameMiddle InitialLast Name
Preferred Name (If Any)
Patient Is

Policy HolderResponsible Party
Sex

MaleFemale
Marital status

MarriedSingleDivorcedSeparatedWidowed

Responsible Party (If Someone Other Than Patient)
Name

First NameMiddle InitialLast Name
Address
Address 2
City, State, Zip
Home Phone
Home Phone Number
Work Phone
Work Phone Number
Work Phone Extension
Cell Phone
Cell Phone Number
Birth Date

MonthDayYear
Social Security Number
Drivers License Number
Insurance Info:

Responsible Party is also a Policy Holder for PatientResponsible Party is Primary Insurance Policy HolderResponsible Party is Secondary Insurance Policy Holder

Detailed Patient Information
Address
Address 2
City
State / Zip
Home Phone
Home Phone
Work Phone
Work Phone
Extension
Cell Phone
Cell Phone
Birth Date

MonthDayYear
Age
Soc. Security Number
Drivers License Number
E-Mail
example@example.com
Employment Status

Full TimePart TimeRetired
Student Status

Full TimePart Time
Medicaid ID
Pref. Dentist
Employer ID
Pref. Pharmacy
Carrier ID
Pref. Hyg.
Additional Comments

Primary Insurance Information
Name of Insured
Relationship to Insured

SelfSpouseChildOther
Insured Soc. Sec Number
Insured Birth Date

MonthDayYear

Employer Information

	Information
Employer Name
Address
Address 2
City, State, Zip

Insurance Company Information

	Information
Insurance Company Name
Address
Address 2
City, State, Zip

Remaining Benefits
Remaining Deductions

Secondary Insurance Information
Name of Insured
Relationship to Insured

SelfSpouseChildOther
Insured Soc. Sec Number
Insured Birth Date

MonthDayYear

Employer Information

	Information
Employer Name
Address
Address 2
City, State, Zip

Insurance Company Information

	Information
Insurance Company Name
Address
Address 2
City, State, Zip

Rem. Benefits
Rem. Deduct

MEDICAL HISTORY
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 you will receive. Thank you for answering the following questions.

Please answer the following. If yes to any of the below, please explain.*

	Yes	No
Are you under a physican's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?

If yes to any of the above, please explain. Please also list all medications you are currently taking (prescription and over the counter). Please also list any major surgeries/operations you have had.

Women, are you:

	Yes	No
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Nursing?

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther

Do you have, or have you had, any of the following?*

	Yes	No
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorders
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice

Have you ever had any serious illness not listed above?

YesNoOther
Comments

SIGNATURE
Signature of patient, parent, or guardian

Clear
Date

MonthDayYear
Should be Empty: