Patient Intake Downloadable PDF Version of This Form Patient Intake Form Date Date Format: MM slash DD slash YYYY General Patient Information* First Middle Last Nickname Sex Date of Birth Age SSN Email Street Address City State Zip Home Phone Business Phone Cell Phone Employer Referred By Dentist Med Drivers Lic Nearest Relative (Not Living With) Phone Former Patient Here?*YesNoMethod of Payment*CashCheckCreditNext Dental Appointment: Date Time I belong to a*PPOHMONeitherPersonal InformationMarital Status*MarriedDivorcedLegally SeparatedWidowSingleEmployment*N/AFull TimePart-timeRetiredStudentN/AFull TimePart-TimeSchool Name/LocationResponsible Party (if self, skip to the next section)SelfSpouseFatherMother Name Home Phone SSN Date of Birth Street Address City State / Province / Region ZIP / Postal Code Employer Phone Secondary Responsible Party (if different from above):SelfSpouseFatherMother Name Home Phone SSN Date of Birth Street Address City State / Province / Region ZIP / Postal Code Employer Phone Primary Dental Insurance Company Employer Business Address Phone Plan Insurance Company Group Name Group Number Identification Number Primary Insured Relationship to Primary Insured Secondary Dental Insurance Company Employer Business Address Phone Plan Insurance Company Group Name Group Number Identification Number Primary Insured Relationship to Primary Insured Dental InformationReason for today's visitEmergencyExamScheduled ProcedureConsultationAre you in any pain?YesNoIf yes, how long have you been in pain?Please indicate if you have any of the following problems by checking off the corresponding box Discomfort, Clicking or Jaw Popping Lost or Broken Fillings Stained Teeth Red, Bleeding or Swollen Gums Teeth Grinding Locking Jaw Sensitive Tooth or Gums Ringing Ears Bad Breath Blisters/Sores in or Around the Mouth Broken/Chipped Tooth Other (please explain)Have you ever required pre-medication?YesNoNot Sure Previous Dentist Phone Last Dental Exam Last Dental X-rays How many times per day do you brush?How many times per week do you floss?What type of toothbrush bristles do you use?SoftMediumHardMedical HistoryAre you taking any of the following medications? Nerve Pills Pain Killers Muscle Relaxer Stimulants Blood Thinners Tranquilizers Insulin Other Medications (please list):Do you have or have had any of the following diseases, medical conditions or procedures? (Please check proper box.)Heart Attack/StrokeYesNoThyroid ProblemsYesNoCancer/TumorsYesNoCosmetic SurgeryYesNoHeart Surger/PacemakerYesNoKidney ProblemsYesNoShinglesYesNoX-ray or Cobalt TreatmentYesNoHeart MurmurYesNoLiver ProblemsYesNoHepatitisYesNoChemotherapyYesNoRhumatic FeverYesNoRespiratory ProblemsYesNoHIV/AIDS/ARCYesNoAsthmaYesNoMitral Valve ProlapseYesNoSinus ProblemsYesNoArthritis/RheumatismYesNoDifficulty BreathingYesNoArtificial ValvesYesNoStomach Problems/UlcersYesNoArtificial Bones/JointsYesNoDiabetes/HypoglycemiaYesNoHeart DiseaseYesNoPsychiatric ProblemsYesNoEmphysemaYesNoLeukemiaYesNoCongenital Heart DefectYesNoVenereal DiseaseYesNoFainting/Seizures/EpilepsyYesNoAnemiaYesNoChest PainsYesNoAlcohol/Drug AbuseYesNoSevere/Frequent HeadacheYesNoHigh/Low Blood PressureYesNoScarlet FevverYesNoTuberculosis TBYesNoFrequent Neck PainYesNoBleeding ProblemsYesNoNervousnessYesNoJaw ProblemsYesNoTMJ/TMDYesNoBack ProblemsYesNoGlaucomaYesNoAre you currently or have you taken in the past (either orally or through IV) any of the following drugs:Actonel (Risedronate) for OsteoporosisYesNoAredia (Pamidronate) for Cancer, PagetsYesNoBonefos (Clondronate) for CancerYesNoBoniva (ibandronate) OsteoporosisYesNoDidronel (Etidronate) PagetsYesNoFosamax (Alendronate) Osteoporosis, PagetsYesNoOstac (Clondronate) CancerYesNoSkelid (Tiludronate) Pagets'sYesNoZometa (Zoledronic Acid) Osteoporosis, CancerYesNoList any other medical condition(s) you have or have hadAre you allergic to the following? Latex Tetracycline Asperin Dental Anesthetics Penicillin/Amoxicillin Not Sure Other (please list)Other Allergies (please list)Do you smoke?YesNo How many per day? How long have your smoked? Other tobacco products?YesNoWhat type of tobacco? How Often? How long? Please rate your general health 1-10Do you wear contact lenses?YesNoNo Have you ever taken the drug Phen-fen or ReduxYesNoFor women onlyAre you taking Birth Control pills?YesNoHow many children have you birthed?Are you currently pregnant?YesNoIf yes, how many months are you?Are you nursing?YesNoTerms of Service Our policy requires payment in full for all services rendered at the time of the visit, unless other arrangements have been made with our office. If the account is not paid in full of the date of services and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. " I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided." Signature (Electronically filling in your name here is equivalent to signing.) Date Adult PatientParent or GuardianSpouseUPDATE (Office Use Only) Initials Date Comments Initials Date Comments Initials Date Comments Enter Security code