�,Womble Gate

American Dentistry

Ellie Suzuki D.D.S. & Akane Suzuki D.D.S.
family, Esthetlcand OrthodonllcC'.ilre

Dear Patient,
Welcome to our practice! Kindly fill out the information below so we may better serve
you regarding follow-ups and recall appointments.
Today's Date ______
Name:
Birthdate:

First-------'/____/____YYYYDDMM

Sex: (M / F)

Last

Address:

CityState

Zip

Tel#l
Tel#2
Email:
Dental Insurance

YesNo

If yes, dental insurance name: (circle one or input other)

BTricare w/United Concordia (Active Duty) (Command Sponsored/Non-Command
Tricare w/Delta (Retired)
Dothers_________ _______________
When will you be leaving Japan (PCS)? _____________________

Sponsor Command: ____________Command phone number:_______How did you hear about us?
ReferralInsurance Website, Insurance list on base
Internet Searchseahawk (Umitaka)
Facebook
Stars & Stripes

Other s __________________________

May 11,2017

MEDICAL HISTORY
Patient Name
Name of Physician/and their specialty
Most recent physical examination
What is your estimate of your general health?

NicknamePurpose
Excellent

DO YOU HAVE or HAVE YOU EVER HAD:

AgeGood

Fair

PoorYES NO

1. hospitalization for illness or injury
2. an allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoridechlorhexidine (CHX)
metals (nickel, gold, silver,latexnuts
fruitother)

3. heart problems, or cardiac stent within the last six months
4. history of infective endocarditis
5. artificial heart valve, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. orthopedic implant (joint replacement)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. pneumonia, emphysema, shortness of breath, sarcoidosis
14. chronic ear infections, tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (e.g., sleep apnea, snoring, sinus)17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes (HbA1c =)24. stomach or duodenal ulcer
25.	digestive or eating disorders (e.g., celiac disease, gastric reflux,bulimia, anorexia)

YES NO
26. osteoporosis/osteopenia (e.g., taking bisphosphonates)
27. arthritis
28.	autoimmune disease(e.g., rheumatoid arthritis, lupus, scleroderma)
29. glaucoma
30. contact lenses
31. head or neck injuries
32. epilepsy, convulsions (seizures)
33. neurologic disorders (ADD/ADHD, prion disease)
34. viral infections and cold sores
35. any lumps or swelling in the mouth
36. hives, skin rash, hay fever
37. STI/STD/HPV
38. hepatitis (type)
39. HIV/AIDS
40. tumor, abnormal growth
41. radiation therapy
42. chemotherapy, immunosuppressive medication
43. emotional difficulties
44. psychiatric treatment
45. antidepressant medication
46. alcohol/recreational drug use

ARE YOU:
47. presently being treated for any other illness
48.	aware of a change in your health in the last 24 hours(e.g., fever, chills, new cough, or diarrhea)
49. taking medication for weight management
50. taking dietary supplements
51. often exhausted or fatigued
52. experiencing frequent headaches
53. a smoker, smoked previously or use smokeless tobacco
54. considered a touchy/sensitive person
55. often unhappy or depressed
56. taking birth control pills
57. currently pregnant
58. diagnosed with a prostate disorder

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect yourdental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years
Drug

PurposeDrug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient’s Signature

Date

Doctor’s Signature

Date
ASA

© 2018 Kois Center, LLC(1-6)
www.koiscenter.com

DENTAL HISTORY
Name______________________________ Nickname_____________________________ Age_________
Referred by__________________________How would you rate the condition of your mouth?
Excellent
Good
Previous Dentist ______________________________How long have you been a patient?___________Months/Years
Date of most recent dental exam ______/______/______ Date of most recent x-rays ______/______/______
Date of most recent treatment (other than a cleaning) ______/______/______
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely

Fair

Poor

WHAT IS YOUR IMMEDIATE CONCERN?______________________________________________________________________________PLEASE ANSWER YES OR NO TO THE FOLLOWING:YES NOPERSONAL HISTORY
1.
2.
3.
4.
5.
6.

Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [____]__________________________________Have you had an unfavorable dental experience?___________________________________________________________________Have you ever had complications from past dental treatment?_________________________________________________________Have you ever had trouble getting numb or had any reactions to local anesthetic?__________________________________________
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?________________________________Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?_______________GUM AND BONE
7.
8.
9.
10.
11.
12.
13.

Do your gums bleed or are they painful when brushing or flossing? ______________________________________________________Have you ever been treated for gum disease or been told you have lost bone around your teeth? ______________________________Have you ever noticed an unpleasant taste or odor in your mouth? _ ____________________________________________________Is there anyone with a history of periodontal disease in your family? _____________________________________________________Have you ever experienced gum recession? ________________________________________________________________________Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?______________Have you experienced a burning or painful sensation in your mouth not related to your teeth?_________________________________TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years? ___________________________________________________________________
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? _________________________
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? ______________________________________
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?___________________________
18. Do you have grooves or notches on your teeth near the gum line? ______________________________________________________
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? __________________________________________
20. Do you frequently get food caught between any teeth?_______________________________________________________________BITE AND JAW JOINT
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) _________________________________
22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?________________________________
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? ______________
24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?_______________________
25. Are your teeth becoming more crooked, crowded, or overlapped? _____________________________________________________
26. Are your teeth developing spaces or becoming more loose? __________________________________________________________
27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?__
28. Do you place your tongue between your teeth or close your teeth against your tongue?_____________________________________
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? ________________________________
30. Do you clench or grind your teeth together in the daytime or make them sore?____________________________________________
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?___32. Do you wear or have you ever worn a bite appliance? ________________________________________________________________

SMILE CHARACTERISTICS
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?_________________________
34. Have you ever whitened (bleached) your teeth? ____________________________________________________________________
35. Have you felt uncomfortable or self conscious about the appearance of your teeth? ________________________________________
36. Have you been disappointed with the appearance of previous dental work? ______________________________________________
Patient’s Signature ________________________________________________________________________________Date _______________________
Doctor’s Signature __________________________________________________________________________________ Date _______________________© 2016 Kois Center, LLC

To order, please visit: www.koiscenter.com

We request a 24 hour cancellation notice for scheduled appointments. A
cancellation fee of 3,000 yen will be charged if a 24 hour notice is not given.

�,W

omble Gate

American Dentistry

Ellie Suzuki D.D.S. & Akane Suzuki 0.0.S.
Famlly, Esthttk IOd Or1hodonllc c.are

Financial Responsibility FormPatient's Name: ______________ Patient DOB: ________As a courtesy, if you have Tricare United Concordia dental insurance, we will file the claims for you. It isvery
important that the correct insurance information is provided at the time of the patient's appointment. If
this information changes, it is the patient's responsibility to update Womble Gate American Dentistry at
the earliest convenience. While we do our best to verify dental benefits prior to your first appointment,
this does not guarantee coverage or payment to Womble Gate American Dentistry. We do accept
payments from United Concordia TriCare; but keep in mind the insurance contract is between you andTriCare.
If requested, we will provide you with a verbal ESTIMATE of your out of pocket expense for any
treatment planned by the doctor. However, please understand that these are strictly estimates and are
not a guarantee that your insurance company will reimburse us/you according to these estimates.
Please note that any difference in payment from your insurance company and your account balance isyour responsibility. While the filing of insurance claims is a courtesy that we extend to all of our active
duty families, all charges are your responsibility from the date the services are rendered. If difficultyarises with payment from the insurance company, we will ask that you contact your carrier to rectify theproblem. All expected insurance balances remaining unpaid after 90 days from the date of service
becomes the immediate responsibility of the patient/account holder.
Payment for out of pockets is due at the time of service.
We request a 24 hour cancellation notice for scheduled appointments. A cancellation fee of up to Y3,000
may be charged if a 24 hour notice is not given.

Patient/Parent Signature: ___________________Date: _______
Revised 5/2017

Womble Gate American Dentistryw-.DrSuzuklDDS.com

Uno Bldg.2F, 13 Ogawacho Yokosuka Kanagawa 2.38·0004Japan
tel: +81-468-74-7260 (English) / +81-468-74-7261 (Japanese)
fax: +81-50-3737-9597 / emall: lnfo@DrSuzukJDDS.com