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Intake Forms

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Preferred Method of Contact

If you are completing this form for another person, what is your relationship to that person?

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you ever had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Have you ever had a serious injury to your head or mouth?
Are you currently experiencing dental pain or discomfort?

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Women Only Are you:

Pregnant?
Taking birth control pills or hormonal replacements?
Nursing?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congenital Heart Problems
Low blood pressure
High blood pressure
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
GE Reflux / persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Recurrent infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
STDs / STIs
Excessive urination
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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