Brenner Dental Associates
Cosmetic and General Dentistry
Date: ________________
Patient’s Name: _________________________________________________ Date of Birth: _________________
Patient’s Address: __________________________________________________ State: ______ Zip: __________
City: ______________________________________________ Cell Phone: _______________________________
E-mail Address: ______________________________________________________________________________
Best time and manner to contact you: ____ AM/PM
Cell __ Text __ Email __ Home Phone __ Work Phone __
Marital Status: ________________________________ Patient’s SS# ____________________________________
Employer: ___________________________________________________________________________________
Business Phone: ____________________________________________________ ext: _______________
Business Address: ______________________________________________________________________
Person Responsible for this Account: _____________________________________________________________
Address and Phone # of this person if different from the patient’s: _____________________________________
___________________________________________________________________________________________
_____________________________________________________ Phone: _______________________________
Dental Insurance Plan: _________________________________________________________________________
Under what Employer is this Insurance Plan? ________________________________________________
_____________________________________________________________________________________
Group and/or Identification # ____________________________________________________________
Under Whose Name is this Insurance Plan? _________________________________________________
Date of Birth of Insured ____________________________ SS# of Insured _________________________
Date of Your Last Dental Visit: _______________________
Reason for Your Last Dental Visit: ________________________________________________________________
My Major Reason for seeking Dental Treatment is: __________________________________________________
How did you hear about us? ____________________________________________________________________
HEALTH HISTORY FORM
Name: ______________________________________________________ Birth Date: ______________________
1. Circle Appropriate Answer (leave blank if you do understand the question)
Yes No Is your general health good?
Yes No Has there been any change in your health in the past year?
Yes No Have you been hospitalized within the past year?
If Yes, why? __________________________________________________________________
Yes No Are you being treated by a physician now?
For what? ____________________________________________________________________
Date of last medical exam: ______________________________________________________
Date of last dental exam: _______________________________________________________
Yes No Have you had any problems with prior dental treatment?
Yes No Are you in pain now?
2. Conditions (you have had in the past, or are experiencing now)
Yes No Chest Pain (Angina)
Yes No Hemophilia
Yes No Abnormal Bleeding
Yes No Hepatitis A
Yes No Allergies
Yes No Hepatitis B
Yes No Anemia
Yes No High Blood Pressure
Yes No Arthritis
Yes No HIV/AIDS
Yes No Artificial Bones
Yes No Kidney Problems
Yes No Artificial Heart Valve
Yes No Low Blood Pressure
Yes No Asthma
Yes No Mitral Valve Prolapse
Yes No Blood Transfusion
Yes No Pace Maker
Yes No Cancer – Chemotherapy
Yes No Pneumocystitis
Yes No Colitis
Yes No Radiation Therapy
Yes No Congenital Heart Defect
Yes No Rheumatic Fever
Yes No Diabetes
Yes No Seizures
Yes No Difficulty Breathing
Yes No Sinus Problems
Yes No Drug Abuse
Yes No Stroke
Yes No Dry Mouth
Yes No Thyroid Problems
Yes No Emphysema
Yes No Tuberculosis
Yes No Epilepsy
Yes No Ulcers
Yes No Fainting Spells
Yes No Venereal Disease
Yes No Fever Blisters
Yes No Yellow Jaundice
Yes No Frequent Headaches
Yes No Vomiting/Nausea
Yes No Heart Attack
Yes No Heart Surgery
ARE YOU TAKING:
Yes No
Tobacco in any Form
Yes No
Any medications, over-the-counter medicines (including aspirin)?
If so, which one(s)? ___________________________________________________________________
ALLERGIES:
Yes
Yes
Yes
Yes
No
No
No
No
Aspirin
Dental Anesthetics
Latex
Metals
Yes
Yes
Yes
Yes
No
No
No
No
Codeine
Erythromycin
Penicillin
Tetracycline
Do you have or have you had any disease or medical problems not listed on this form?
Explain: ____________________________________________________________________________________
___________________________________________________________________________________________
If female, please complete the following:
Yes
Yes
Yes
Yes
No
No
No
No
Are you taking birth control pills?
Are you pregnant? If Yes, # of weeks: ________
Are you nursing?
Are you taking any “Bone Building” drugs, such as: Fosamax, Aridia, Boniva, Actonel,
Others not listed: ___________________________
To the best of my knowledge, I have answered every question completely and accurately. I will inform my
dentist of any change in health and/or medication.
Patient or Guardian Signature: _____________________________________________ Date: ________________
Additional Notes: _____________________________________________________________________________
___________________________________________________________________________________________
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