Patient’s name: ____________________________________________________ date of birth: ______________

Health Information and History
Patient’s Name: _______________________________________________________ Date of Birth: ______________
If You are Completing This form For Another Person: Your Name:________________________________________ Phone:________________ Relationship:__________________ Emergency Contact:(If Not Listed Above)
Name:____________________________________________ Phone: ________________ Relationship:__________________
Primary Physician: __________________________________ Phone: ________________ City & State:__________________
Date of Last Physical Examination: _________________ Date of Last Blood Test/Workup: ____________________
Other Physicians & Specialists
Name: _________________________ Specialty: _______________ Phone: _____________ City & State: ____________ Name: _________________________ Specialty: _______________ Phone: _____________ City & State: ____________ Within the Last 3 Years Have You Been Hospitalized or Had Surgery?
If Yes, Please Give Reasons and Dates: __________________________________________________ Have You Ever Been Instructed to Take ANY Medications or
Take ANY Special Precautions Before Any Dental Appointments*?
If Yes, Please Explain: ________________________________________________________________ 1. Are You Taking ANY Drugs, Medications, or Treatments at This Time?
(If You Brought a Complete Written List With You, Give That to the Receptionist Instead) Prescribed_________________________________________________________ ____________________________________________________________ u.Over- The- Counter Medications (Such as Aspirin, Advil, Allergy Medication, Sleeping Aids, Etc.) ____________________________________________________________
v.Vitamins, Natural or Herbal Preparations and/or Dietary Supplements
____________________________________________________________ ____________________________________________________________ x. Are You Having or Ever Had Radiation or Chemotherapy Treatments*?
If Yes, for How Long?______________ Name of Facility Performing the Therapy:_______________ 2. Are You Allergic to or Have You Ever Experienced an Unusual Reaction to:
3. Are You Allergic to or Have You Ever Had Any Reaction to Any of the Following Drugs?
___Tranquilizers (Valium) ___Tetracycline ___Codeine ___Aspirin / Ibuprofen (Advil, Motrin, Nuprin) ___Keflex (Cephalexin) ___Sulfa Drugs ___Iodine 3z. Have You Had An Allergic Reaction or Unusual Response to
ANY Other Medications, Drugs, Pills, or Treatments?
List :___________________________________________________________ Continued on Next Page…. HH04-1
Do You Have or Have You Ever Had Any of the Following (Please Check Yes or No for Each Question)
Yes No Yes No
4. a. Congenital
d. Tuberculosis, Emphysema or Lung Disorder h. Rheumatic Heart Disease / Rheumatic Fever* ___ ___
i Heart Murmur* ___ ___
j. Heart Valve(s) Damage / Mitral Valve Prolapse* ___ ___
l. Ulcers, Acid Reflux, or Stomach Problems m. A Compromised Immune System*
(Lupus, HIV, AIDS, Radiation Immune Problem, etc) n. An Active Sexually Transmitted Disease (STD) ___ ___ p. Been Treated for Any Psychiatric Condition q. Hemophilia or Bleeding Disorder ___ ___ r. Excessive Bleeding from Any Cut or Incident ___ ___ 6. Women Only: Yes No
t. Any Artificial Joint, Joint Surgery,or Prosthesis* ___ ___
If Yes, What is Your Due Date: ___________ Do You Think You Might Be Pregnant ___ ___ u. Hepatitis, Jaundice, or Other Liver Problems Are You Taking Hormone Replacement Therapy ___ ___ w. An Organ Transplant*

7. Do You Have Any Other Conditions, Diseases, or Medical Problems, or is There ANY Other
Information That You Would Like Us to Know About or That We Should Be Made Aware Of?
If So, Please Explain: _______________________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Dental and Oral Health Information
If You are a New Patient to the Benjamin Dental Group:
Date of Last Dental Visit_________ Dentist’s Name _____________________________City & State______________________ Please Describe Any Specific Dental Problem or Discomfort You Are Having at This Time.
______________________________________________________ How Long Has It Been Present?___________________
If You Have Had Any of the Following Dental Care Please List the Dentists and Approximate Dates:
Periodontal (Gum) Treatment or Surgery _______________________________________________________________
“Braces” or Any Type of Orthodontic Treatment: ________________________________________________________
Dental Implants:____________________________________________________________________________________
Any Other Type of Oral Surgery: ______________________________________________________________________
Do You Have or Had Any of the Following or Noticed Any of These Signs or Symptoms in Your Head, Neck, or Mouth:
(Please Check Yes or No for Each Question)
Yes No Yes No
A Clicking, Snapping or Difficulty When Chewing? ___ ___ Heat , Cold, Sweets, or Biting Pressure? ___ ___ An Unpleasant Taste or Persistent Bad Breath? ___ ___ Difficulty Speaking or Changes in Your Voice? ___ ___ Does Food Catch Between Your Teeth? ___ ___ Difficulty Moving Your Tongue or “Tongue Tied” ___ ___ Do Your Gums Bleed When Brushing? ___ ___ Red, Swollen, Tender, Bleeding or Sores Gums? ___ ___ Changes in the Way Your Teeth Fit Together? ___ ___ Gums That Have Pulled Away from the Teeth? ___ ___ A Color Change of the Tissues in Your Mouth? ___ ___ Pain, Tenderness, Numbness, or Earaches? ___ ___ Avoid Any Area When Brushing or Chewing? ___ ___ Any Lumps Swelling or Swollen Glands? ___ ___ Do You Clench or Grind Your Teeth? ___ ___ Sores, Ulcers, or Rough Spots in Your Mouth?
Your Dental Health:
How Do You Rate Your Overall Dental Health?
How Many Times a Day Do You Brush Your Teeth?_____ How Many Times a Week Do You Floss Your Teeth? _____
Do You Use Any of the Following? (Please Check Yes or No for Each Question) Yes No
Fluoride Treatments or Supplements at Home? If Yes, What:________________________________________ ___ ___ Mouthwashes or Oral Rinses? If Yes, What Brand? ______________________________________________ ___ ___ Do You Have Any Missing Teeth That Have Not Been Replaced? ___ ___
Why Have You Not Had Them Replaced?_________________________________________________________ Do You Wear Any Removable Dental Appliances? If Yes, What Type and For How Long? ___________________ ___ ___
Have You Ever Had Your Teeth Whitened or Bleached? ___ ___
Would You Like to Have Your Teeth Whitened or Bleached? ___ ___ How Do You Feel About the Appearance of Your Smile and What Else Would You Change If You Could?
_____________________________________________________________________________________ Are You Concerned About the Finances Required to Return Your Mouth to Excellent Health?
Are You Frustrated Because You Always Need Something Treated or Repaired When You Visit a Dentist? ___ ___
Do You Feel You Will Eventually Wear Artificial Dentures? ___ ___
Have You Ever Had Any Complications From An Extraction or Dental Treatment? ___
If Yes, Please Explain______________________________________________________________________
Have You Ever Had Any Other Dental Conditions, Major Trauma or Injury to Your Head, Neck, or Mouth? ___ ___
If Yes, Please Specify: ___________________________________________________________________ Oral Health Risk Factors
1. Do You or Have You EVER Smoked?
(If No, Proceed to Question 2)
The Amount that You are Presently Smoking
Completely) ___2 or More Packs of Cigarettes per Day* ___A Few Cigarettes Daily* ___Cigars on a Daily / Regular Basis * ___Less than1 Pack of Cigarettes per Day* ___An Occasional Pipe Smoker* ___1-2 Packs of Cigarettes per Day * ___A Pipe on a Daily / Regular Basis* If You Have Quit Smoking, When Did You Quit?
___Less than 6 Months Ago* ___1 to 3 Years Ago* ___6 Months to a Year* ___Over 3 Years Ago How Many Years Have You or Did You Smoked?
2. Do You or Have You EVER Chewed Tobacco or Used Snuff?
(If No, Proceed to Question 3)
Are You STILL Using Smokeless Tobacco or Snuff?*
If No, WHEN Did You Quit?
___Less than 6 Month Ago* ___1 to 3 Years Ago* ___6 How Many Years Did You or Have You Used Smokeless Tobacco?
___Less than 1 Year ___1-2 Years ___2-5 Years ___Over 5 Years* 3. Approximate Average Amount of Alcoholic Beverages Presently Consumed per Week?
4. Do You Have or Have You Ever Had a Substance Abuse Problem?*
Describe____________________________________________________________________________ 5. Do You Presently Use Any Recreational Drugs?*
List________________________________________________________________________________ 6. Do You Have or Have You Ever Had an Eating Disorder?*
If Yes, Please Specify: ________________________________________________________________ 7. Do You Have or Ever Had Any Head, Neck or Mouth Piercing(s)? (Other than Ears)
List _______________________________________________________________________________ APPOINTMENTS— A minimum charge will be made for failed or canceled appointments without prior notification of at least 48 hours. This fee covers only a portion of the overhead such as salaries, electric, heat, etc., which still has to be paid whether you are present or not. Once an appointment is made, please remember this time has been reserved just for you. Any change in your appointments affects many patients; please be considerate. INSURANCE—For your convenience, we will complete any forms required by your dental insurance company. Your signature below authorizes the release of any information regarding your dental claims to your insurance carrier(s). It also authorizes payment directly to our office. It is your responsibility, however, to cover the balance of treatment cost, or to cover the entire cost if your insurance should fail to provide coverage. We do not render our services on the basis that insurance will pay any or all of our charges. Each fee is individual for the individual patient. PAYMENT— Payment is expected when services are rendered, unless other arrangements are made in advance. A service charge of 2% per month (equivalent to 24% PER ANNUM), will be added to the unpaid balance of all accounts over 30 days. In the event we must hire an attorney or collection agency to collect this debt, you will be responsible for the payment of all costs and expenses, including all collection agency fees, court costs and reasonable attorney’s fees. CONSENT—To the best of my knowledge, all of the preceding answers are correct. If I ever have any change in my health, or if my medications change, I will inform this office at the next appointment without fail. I hereby consent to allow diagnosis, proper dental care and treatment to be performed by this practice for myself or the above named individual until further notice. I understand there are no guarantees or warranties in health or dental care. Signature_______________________________________________________ Date ___________________

Source: http://www.benjamindental.com/HH04%20Health%20Information%20and%20History.pdf