Personal Information ** All Fields Mandatory **
Date of last visit:
Date of Med. History:
Social Security No:
Your Cell Phone #:
Emergency Contact #:
Who referred you?:
Name of other family members seen here:
Parent / Guardian:
If Female please answer the following:
Are you taking birth control pills? Y
Are you pregnant? Y
if Y, # of weeks
Are you nursing? Y
Please answer the following:
Do you smoke or use tobacco? Y
Artificial Heart Valve
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Pain in Jaw Joints
Sickle Cell Disease
Dental History ** All Fields Mandatory **
Do you have specific dental problem? Describe
Do you have dental examinations on a routine basis? Last Visit
Do you think you have active decay or gum disease?
Do you brush and floss on a routine basis? Discuss
Do your gums ever bleed? Discuss
Do you like your smile? Why?
Does your food catch between your teeth? Any loose teeth?
Do you want to keep your remaining teeth?
Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind?
Have your past experiences in a dental office always been positive?
Do you smoke or chew? Any sores or growths in the mouth? Discuss
Name of previous dentist (optional)
Date of last full mouth x-rays (16 small films or panoramic):
Medical History ** All Fields Mandatory **
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation? Discuss
Have you ever had a serious injury to your head or neck? Discuss
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? What?
Are you on a special diet? Discuss
Copyright 2010 Dr. Steven B. Andreaus, DDS