Patient Intake Form

Downloadable PDF Version of This Form

Todays Date:

General Patient Information:

First Name:

MI:

Last Name:

Nickname:

Sex:

M F

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?
Yes No

Method of Payment:

Cash Check
Credit

Next Dental Appointment:
Date:
Time:

I belong to a:

PPO HMO
Neither

Personal Information:

Marital Status: Married Divorced Legally Separated Widow Single
Employment: N/A FullTime PartTime Retired
Student: N/A Full Time Part Time School Name/Location

Responsible Party (if self, skip to the next section):

Self Spouse Father Mother Other:
Name:	Home Phone:	SSN: Date of Birth:
Street Address:
City:	State:	Zip:
Employer:	Phone:

Secondary Responsible Party (if different from above):

Spouse Father Mother Other:
Name:	Home Phone:	SSN: Date of Birth:
Street Address:
City:	State:	Zip:
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 Information:

Reason for today's visit:

Emergency Exam Scheduled Procedure Consultation

Are you in any pain? Yes No
If 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?

Yes No Not 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? Soft Medium Hard

Medical History:

Are 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/Stroke

Yes No

Thyroid Problems

Yes No

Cancer/Tumors

Yes No

Cosmetic Surgery

Yes No

Heart Surger/Pacemaker

Yes No

Kidney Problems

Yes No

Shingles

Yes No

X-ray or Cobalt Treatment

Yes No

Heart Murmur

Yes No

Liver Problems

Yes No

Hepatitis

Yes No

Chemotherapy

Yes No

Rhumatic Fever

Yes No

Respiratory Problems

Yes No

HIV/AIDS/ARC

Yes No

Asthma

Yes No

Mitral Valve Prolapse

Yes No

Sinus Problems

Yes No

Arthritis/Rheumatism

Yes No

Difficulty Breathing

Yes No

Artificial Valves

Yes No

Stomach Problems/Ulcers

Yes No

Artificial Bones/Joints

Yes No

Diabetes/Hypoglycemia

Yes No

Heart Disease

Yes No

Psychiatric Problems

Yes No

Emphysema

Yes No

Leukemia

Yes No

Congenital Heart Defect

Yes No

Venereal Disease

Yes No

Fainting/Seizures/Epilepsy

Yes No

Anemia

Yes No

Chest Pains

Yes No

Alcohol/Drug Abuse

Yes No

Severe/Frequent Headache

Yes No

High/Low Blood Pressure

Yes No

Scarlet Fevver

Yes No

Tuberculosis TB

Yes No

Frequent Neck Pain

Yes No

Bleeding Problems

Yes No

Nervousness

Yes No

Jaw Problems

Yes No

TMJ/TMD

Yes No

Back Problems

Yes No

Glaucoma

Yes No

Are you currently or have you taken in the past (either orally or through IV) any of the following drugs:

Actonel (Risedronate) for Osteoporosis

Yes No

Aredia (Pamidronate) for Cancer, Pagets

Yes No

Bonefos (Clondronate) for Cancer

Yes No

Boniva (ibandronate) Osteoporosis

Yes No

Didronel (Etidronate) Pagets

Yes No

Fosamax (Alendronate) Osteoporosis, Pagets

Yes No

Ostac (Clondronate) Cancer

Yes No

Skelid (Tiludronate) Pagets's

Yes No

Zometa (Zoledronic Acid) Osteoporosis, Cancer

Yes No

List any other medical condition(s) you have or have had:

Are you allergic to the following?

Latex Tetracycline Asperin Dental Anesthetics
Penicillin/Amoxicillin Not Sure

Other (please list):

Other Allergies (please list):

Do you smoke?

Yes No

How many per day?
How long have your smoked?

Other tobacco products?

Yes No

What type of tobacco?

How often? How long?

Please rate your general health 1-10:

Do you wear contact lenses?

Yes No

No Have you ever taken the drug Phen-fen or Redux

Yes No

No For women only:

Are you taking Birth Control pills?

Yes No

How many children have you birthed?

Are you currently pregnant?

Yes No

If yes, how many months are you?

Are you nursing?

Yes No

Terms 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 Patient Parent or Guardian Spouse

UPDATE (Office Use Only)

Initials: Date:
Comments:

Enter Security Code:

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