benyountdds.com - Dental and Medical History

Name

First Name Last Name

What would you like us to do today?

Are you in dental discomfort today?

Yes No

Former Dentist

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Dentist's Email

example@example.com

Phone

Please enter a valid phone number.

Date of last dental exam

Date

Date of last x-rays

Date

Bad breath *

Yes No

Bleeding Gums *

Yes No

Clicking or popping jaw *

Yes No

Food collection between teeth *

Yes No

Grinding or clenching teeth *

Yes No

Loose teeth or broken fillings *

Yes No

Periodontal treatment *

Yes No

Sensitivity to cold *

Yes No

Sensitivity to hot *

Yes No

Sensitivity to sweets *

Yes No

Sensitivity when biting *

Yes No

Sores or growths in mouth *

Yes No

How often do you brush? *

How often do you floss? *

How do you feel about the appearance of your teeth? *

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? *

Yes No

Other information about your dental health or previous treatment

Physician's Name *

Phone Number *

Please enter a valid phone number.

Date of last visit

Date

Have you had any serious illnesses or operations? *

No Yes

If yes, describe

Are you currently under physician care? *

No Yes, describe

Have you ever had a blood transfusion? *

No Yes, give approximate dates

Have you ever taken Fen-Phen/Redux? *

No Yes

Have you ever used a bisphosphonate medication? Brand names include Fosamax, Actonel, Atelvia, Didronel and Boniva. *

No Yes

Are you pregnant?

No Yes

Nursing?

No Yes

Taking birth control pills?

No Yes

AIDS/HIV Positive *

Y N

Describe *

Anaphylaxis *

Y N

Describe *

Anemia *

Y N

Describe *

Arthritis, Rheumatism *

Y N

Describe *

Artificial Heart Valves *

Y N

Describe *

Artificial Joints *

Y N

Describe *

Asthma *

Y N

Describe *

Atopic (allergy prone) *

Y N

Describe *

Back Problems *

Y N

Describe *

Blood disease *

Y N

Describe *

Cancer *

Y N

Describe *

Chemical dependency *

Y N

Describe *

Chemotherapy *

Y N

Describe *

Circulatory problems *

Y N

Describe *

Cortisone treatments *

Y N

Describe *

Cough, persistent *

Y N

Describe *

Cough up blood *

Y N

Describe *

Diabetes *

Y N

Describe *

Epilepsy *

Y N

Describe *

Fainting *

Y N

Describe *

Food allergies *

Y N

Describe *

Glaucoma *

Y N

Describe *

Headaches *

Y N

Describe *

Heart murmur *

Y N

Describe *

Heart problems *

Y N

Describe *

Hemophilia/Abnormal Bleeding *

Y N

Describe *

Herpes *

Y N

Describe *

Hepatitis *

Y N

Describe *

High Blood Pressure *

Y N

Describe *

Jaw pain *

Y N

Describe *

Kidney disease or malfunction *

Y N

Describe *

Liver disease *

Y N

Describe *

Material allergies (latex, wool, metal, chemicals) *

Y N

Describe *

Mitral valve prolapse *

Y N

Describe *

Nervous problems *

Y N

Describe *

Pacemaker/Heart Surgery *

Y N

Describe *

Psychiatric care *

Y N

Describe *

Rapid weight gain or loss *

Y N

Describe *

Radiation treatment *

Y N

Describe *

Respiratory disease *

Y N

Describe *

Rheumatic/Scarlet fever *

Y N

Describe *

Shingles *

Y N

Describe *

Shortness of breath *

Y N

Describe *

Skin rash *

Y N

Describe *

Spina Bifida *

Y N

Describe *

Stroke *

Y N

Describe *

Surgical implant *

Y N

Describe *

Swelling of feet or ankles *

Y N

Describe *

Thyroid disease or malfunction *

Y N

Describe *

Tobacco/Controlled Substances/Marijuana *

Y N

Describe *

Tonsillitis *

Y N

Describe *

Tuberculosis *

Y N

Describe *

Ulcer/Colitis *

Y N

Describe *

Venereal disease *

Y N

Describe *

Is patient currently taking any medications? If yes, list all:

Does patient have drug allergies? If yes, list all:

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature *

Clear

Date *

Date

Payment is due in full at time of treatment, unless prior arrangements have been approved.

Dental and Medical History

Dental History

Check yes or no if you have had problems with any of the following:

Medical History

Women

Check yes or no whether you have had any of the following:

Authorization