Personal Information ** All Fields Mandatory **
Patient's Name:
Today's Date:
Address:
Date of last visit:
Date of Med. History:
City:
State:
Zip:
Email:
Home Phone:
Work Phone:
Birth Date:
Social Security No:
Marital Status:
Employer:
Your Cell Phone #:
Emergency Contact:
Emergency Contact #:
Who referred you?:
Name of other family members seen here:
Pharmacy:
Parent / Guardian:

Sex:  M F   If Female please answer the following:
Are you taking birth control pills?   Y N
Are you pregnant?   Y N  if Y, # of weeks
Are you nursing?   Y N
  Please answer the following:
Do you smoke or use tobacco?   Y N

Height:       Weight:  
 Conditions
Abnormal Bleeding Heart Murmur Taken Fen-Phen
Alcohol Abuse Heart Surgery Thyroid Problems
Anemia Hemophilia Tuberculosis
Arthritis Hepatitis A Ulcers
Artificial Heart Valve Hepatitis B Venereal Disease
Artificial Joints High Blood Pressure Yellow Jaundice
Asthma Kidney Problems Blood Transfusion
Liver Disease Bruise Easily Low Blood Pressure
Cancer-Chemotherapy Mitral Valve Prolapse Colitis
Night Sweats Diabetes Pace Maker
Difficulty Breathing Pain in Jaw Joints Drug Abuse
Pneumocystitis Emphysema Pre-Med Required
Epilepsy Psychiatric Problems Fainting Spells
Radiation Therapy Fever Blisters Rheumatic Fever
Frequent Headaches Seizures Glaucoma
Sickle Cell Disease HIV+ AIDS Sinus Problems
Heart Attack Stroke  
 Allergies
Aspirin Codeine Dental Anesthetics
Erythromycin Jewelry Latex
Metals Penicillin Tetracycline
 Dental History ** All Fields Mandatory **
Do you have specific dental problem? Describe Y N
Do you have dental examinations on a routine basis? Last Visit Y N
Do you think you have active decay or gum disease? Y N
Do you brush and floss on a routine basis? Discuss Y N
Do your gums ever bleed? Discuss Y N
Do you like your smile? Why? Y N
Does your food catch between your teeth? Any loose teeth? Y N
Do you want to keep your remaining teeth? Y N
Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind? Y N
Have your past experiences in a dental office always been positive? Y N
Do you smoke or chew? Any sores or growths in the mouth? Discuss Y N
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? Y N Why?   Who?   Phone
Have you ever been hospitalized or had a major operation? Discuss Y N
Have you ever had a serious injury to your head or neck? Discuss Y N
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? What? Y N
Are you on a special diet? Discuss Y N
 
 

Copyright 2010 Dr. Steven B. Andreaus, DDS