Medical history - adult

DEBORAH G. ANDERS, DDS, PA 3094 US 70 HWY
GENERAL DENTISTRY BLACK MOUNTAIN, NC 28711
PATIENT REGISTRATION AND HEALTH HISTORY REVIEW
SELF: Date_______________________
Patient’s Full Name_____________________________ How do you prefer to be addressed? ______________
Address________________________________________________ Home Phone # ______________________
City________________________State_______Zip_________Work # & Ext. _____________________________
Male or Female Single ( ) Widowed ( ) Married ( ) Divorced ( ) Separated ( )
SS#___________________ Date of Birth ____/____/______
Who may we thank for telling you about our office?__________________________________________________
Employed By____________________________________________How long ___________________________
Driver’s License #_______________ Names of your children _________________________________________
SPOUSE AND/OR RESPONSIBLE PARTY:
Full Name __________________________________________________________Birthdate _____/_____/_____
Employed By__________________________________________Work # & Ext. # _________________________
Home Address (if different than patient)___________________________________________________________
SS# _______________________________ Driver’s License # ________________________________________
In case of emergency, who should be notified? ____________________________ Phone # _________________

CORRECT ANSWERS TO THE FOLLOWING QUESTIONS WILL ALLOW DR. ANDERS AND OUR
TEAM TO TREAT YOU ON A MORE INDIVIDUAL BASIS, PROVIDING THE CARE APPROPRIATE
FOR YOUR PARTICULAR NEEDS. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.
DENTAL HISTORY
Purpose of this appointment: ___________________________________________________________________
Have you ever had serious trouble associated with dental treatment? (Y)(N)
Explain:____________________________________________________________________________________
Are you concerned about any materials or procedures in your mouth? (Y) (N)
Do you have fluoride in your drinking water? (Y)(N)
Date of last dental visit?_________________ Last dental x-rays?______________________ Did you visit your
dentist on a regular basis?(Y)(N) Please give us the name of your previous dentist ________________________
Address: ___________________________________________________________________________
Have you ever fainted during a dental appointment? (Y)(N) Does your physician require you to take antibiotics
prior to dental work? (Y)(N) Does dental treatment make you nervous? No Slightly Moderately Extremely
Do you or have you had any of the following? Circle yes or no.
Periodontal disease (Pyorrhea) (Y)(N)

These are the things that are important to me about my dental health:
I a) think the appearance of my mouth/smile is excellent b) am satisfied with the appearance of my mouth/smile
c) am dissatisfied with the appearance of my mouth/smile.
I a) will do anything to keep my natural teeth b) want to keep my natural teeth, but have a certain budget of
time and money that I am willing to spend on them. c) don’t think my teeth can be saved.
I a) have always done the best that was recommended for my dental health b) have not done what dentists
have recommended to me c) rarely go and don’t care much about having any dental work completed.
I think my present state of dental health is a) Excellent b) Good c) Poor.
If you could change your smile, what would you want to be different?____________________________________
MEDICAL HISTORY
Circle Allergies You have: Penicillin Erythromyocin Novocaine Codeine Aspirin Have you lost or gained more than 10 lbs. in recent months? (Y)(N) Had a persistent cough for more than 3 weeks? (Y)(N) Had night sweats? (Y)(N) Coughed up blood? (Y)(N) Are you under the care of a Physician?(Y)(N) If yes, for what conditions?_______________________________ Have you been hospitalized/had a serious illness in the last 5 years? (Y)(N) Explain: ___________________________________________________________________________________ Have you ever had surgery/radiation or chemotherapy for a tumor, growth or other condition in your mouth, lips, neck or face? (Y)(N) Explain: ___________________________________________________________________ Please give your Physician’s Name:__________________________________Last physical _________________ Physician’s Phone # Address: Please continue to other side of this form

Do you drink more than 2 alcoholic beverages a day? (Y)(N)
Do you use tobacco products? (Y)(N) What form? ______________How Much? ___________How Long?_____
Are you pregnant or trying to get pregnant or nursing? (Y) (N) Due date: ______________________________
Have you had any fever blisters/canker sores on your lips, gums or body? (Y)(N)
Pain in chest upon exertion? (Y)(N) Short of breath after mild exercise? (Y)(N)
Do you or have you had any of the following? Check yes or no
Nose/Throat Infection
*Artificial heart valve
*Bacterial endocarditis
*Artificial hip, knee or other joint (Y) (N)
*Any type of transplant
(Y) (N) * Antibiotic pre-medication may be required prior to appointment

Please use this space to list dates and circumstances for any serious problems that you have checked above:
Is there any condition or problem not listed above that we should know about or any activity your physician says
you can not do? Explain:
Have you ever taken Fen-Phen? (Y) (N) Emsam ? (Y) (N) Azobactin? (Y) (N)
List names of medication (prescription or illegal) you are currently taking and dosage below: (Including patches,
inhaler or injections as well as birth control pills, AZT or other drugs for HIV)
1. _____________________ 2. ________________________3. ______________________
4. _____________________ 5. ________________________6. ______________________
If you are taking antidepressants, especially Emsam or Strattera, you will find that you will not stay
anesthetized for long and it is not usually beneficial to use anesthetics that contain epinephrine. This is also true
for medications to treat: ADD/ADHD, Narcolepsy, Obesity, Enuresis, Decongestion, Sleep Disorders,
Antipsychotics, Beta Blockers, MAOI’s and Bronchodilators.

To the best of my knowledge, all of the preceding answers are correct. I understand that antibiotics may reduce
the effectiveness of birth control pills and I should use alternative forms of birth control if I have to take antibiotics.
If I have any changes in my health or medications, I will inform your office at my next appointment.
I understand that I will be responsible for any legal and/or collection fees. I understand and agree that I am
ultimately responsible for payments of professional services regardless of whether I have dental insurance.
I authorize any hospital, clinic, physician or surgeon to furnish Dr. Anders or her staff with any and all
information concerning any medial problems or infectious diseases, and alcohol and drug problems that I
possess. Copies of my medical records may be sent to Dr. Anders’ office. A copy of this authorization shall be
considered as valid as the original.
SIGNATURE: _______________________________________________________________________________
o I give my approval for a Credit Report to be obtained regarding my credit history in order to o I do not consent for a Credit Report. I understand that if I don’t give approval that credit or payment arrangements can not be extended to me and that payment for service is due at each visit in full (regardless of whether I have dental insurance). SIGNATURE:_______________________________________________________________________________ Our team is dedicated to the idea that all people should have the knowledge to retain their
natural teeth for their lifetime. Preventive measures, high quality care, and cooperation
combined with timely treatment make it possible for most people to retain their natural teeth
with optimum comfort, function, and appearance. We will do everything we can to help you
reach your goals for dental health.
Medical History-Adult.doc (updated 12/2010)

Source: http://www.smileinblackmountain.com/pdf/health-history.pdf