MARK L. BENESH D.M.D. M.B.A                                                          PATIENT QUESTIONNAIRE

 

 

PATIENT NAME: ________________________________  ADDRESS: ___________________________

 

CITY: _______________________STATE: _______ZIP: ___________HOME PHONE: ______________

 

WORK PHONE: _________________ FAX #_______________ SEX: ___ MARITAL STATUS: ______

 

DATE OF BIRTH: _____________ SOCIAL SECURITY #: _________________________

 

DRIVER’S LICENSE #: ___________________________________

 

BILLING NAME/ADDRESS:  ____________________________________________________________

 

DENTAL INSURANCE (Y/N)______ SUBSCRIBER’S NAME: _________________________________

 

SUBSCRIBER’S INSURANCE ID # _____________________SUBSCRIBER’S DOB ____________

 

INSURANCE COMPANY’S NAME: ______________________________ PHONE: _________________

 

ADDRESS: _____________________________ CITY: _______________ STATE: ______ ZIP: _______

 

REFERRED BY: __________________________________________________

 

Are you in GOOD HEALTH?                                YES _______ NO ______

 

Do you take MEDICINE?                                YES _______ NO ______

 

List of medicine you are currently taking. ____________________________________________________

______________________________________________________________________________________

 

Have you had a SERIOUS ILLNESS or OPERATION?                                YES ______ NO ______

 

If so what illness or operation? _____________________________________________________________

 

Do you have a PHYSICIAN? (name) _________________________                                YES ______ NO ______

 

Are you ALLERGIC TO ANY DRUGS?                                 YES ______ NO ______

 

If so, what drugs are you allergic to? ________________________________________________________

 

Do you have problems with DENTAL SURGERY or TREATMENT?                                YES ______ NO ______

 

Do you SMOKE ?                                 YES ______ NO ______

 

Do you have BREATHING PROBLEMS?                                 YES ______ NO ______

 

Were you ever exposed to TUBERCULOSIS?                                 YES ______ NO ______

 

Do you have ASTHMA, HAY FEVER, ALLERGIES or HIVES?                                 YES ______ NO ______

 

Did you ever have STOMACH ULCERS?                                 YES ______ NO ______

 

Did you ever have KIDNEY DISEASE?                                 YES ______ NO ______

 

Did you ever have LIVER DISEASE, JAUNDICE OR HEPATITIS?                                YES ______ NO ______

 

Could you have exposed to the AIDS VIRUS?                                YES ______ NO ______

 

Do you have ARTHRITIS or RHEUMATISM?                                YES ______ NO ______

 

Do you have EPILEPSY, SEIZURES or FAINTING SPELLS?                                YES ______ NO ______

 

Do you have DIABETES or LOW BLOOD SUGAR?                                 YES ______ NO ______

 

Do you have problems with BLEEDING?                                YES ______ NO ______

 

Do you have a THYROID PROBLEM? (hyper,hypo,tumor?)                                YES ______ NO ______

 

Are you being treated for GLAUCOMA?                                YES ­­______ NO ______

 

Do you have an IMPLANT? (hip,eye,heart valve, artery,joint)                                YES ______ NO ______

 

Do you have any HEART PROBLEMS?                                YES ______ NO ______

 

Do you have a HEART MURMUR?                                YES ______ NO ______

 

Do you have IRREGULAR HEART BEATS or a PACEMAKER?                                YES ______ NO ______

 

Do you get CHEST PAIN, ANGINA or CORONARY INSUFFICIENCY? YES ______ NO ______

                               

Did you have RHEUMATIC FEVER or RHEUMATIC HEART DISEASE? YES ______ NO _____                   

 

Do you have a CONGENITAL HEART DEFECT?                                YES ______ NO _______

 

Did you ever have a HEART ATTACK?                                YES ______ NO _______

 

Did you ever have a STROKE?                                YES ______ NO _______

 

Do you have HIGH BLOOD PRESSURE?                                YES ______ NO _______

 

Do you have LOW BLOOD PRESSURE?                                YES ______ NO _______

 

Do you have ARTERIOSCLEROSIS?                                YES ______ NO ______

 

Are you PREGNANT?                                YES ______ NO ______

 

Do you have PROSTATE PROBLEMS?                                YES ______ NO ______

 

PHARMACY NAME/PHONE NUMBER: _______________________________________________

 

In case of an emergency, Notify __________________________relationship/phone#______________

 

All accounts are due and payable at the time of you visit unless other arrangements are made with our office manager prior to your visit. All accounts that are not paid at the time of service are subject to a 2% finance charge per month on the unpaid balance.

 

PATIENT SIGNATURE: ________________________________ DATE: _______________________