Please complete this form for new patients ages 18 and over.

*Indicates a required field.

Today's Date *
Today's Date
Patient Information
Patient's Name *
Patient's Name
Address *
Mobile Phone *
Mobile Phone
Home Phone
Home Phone
Work Phone
Work Phone
Gender *
Birthday *
How did you hear about our office?
If applicable
Emergency Contact
Emergency Contact's Name *
Emergency Contact's Name
Phone *
Insurance/Financial Information
Name of person responsible for payment; please include phone number and contact information if not listed above
Insurance Company Name (Delta Dental, Cigna etc)
Name of Insured
Name of Insured
Subscriber's Date of Birth
Subscriber's Date of Birth
Insurance Company Name (Delta Dental, Cigna etc)
Name of Insured
Name of Insured
Subscriber's Date of Birth
Subscriber's Date of Birth
Medical History
Date of Most Recent Physical Exam
Date of Most Recent Physical Exam
Are you currently being treated by a physician at this time? *
Cardiologist, Endocrinologist or other specialist if applicable
Are you taking any medication (prescription, over the counter, vitamin or dietary supplement)? *
Have you ever been hospitalized, had surgery or a significant injury/illness that was treated in the emergency room? *
Have you ever had a reaction to or problem with an anesthetic? *
Have you ever ever had a reaction or allergy to an antibiotic, sedative or any other medication? *
Are you allergic to latex, or anything else such as metals, dyes, or acrylics? *
Do you smoke? *
Do you drink alcohol? *
If yes, please describe
Review of Systems
Sinusitis, chronic adenoid/tonsil infections *
Sleep apnea, snoring, mouth breathing, or excessive gagging *
Difficulty chewing and/or swallowing, or aspiration pneumonia *
Congenital heart defect/disease, heart murmur, rheumatic fever or rheumatic heart disease *
Irregular heart beat or high blood pressure *
Artificial Heart Valve *
Stroke(s) *
Asthma, reactive airway disease, wheezing or breathing problems? *
Cystic fibrosis *
Pneumonia or other serious infections *
Jaundice, hepatitis, or liver problems *
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems *
Prolonged diarrhea, unintentional weight loss, concern with weight, or eating disorder *
Celiac disease, gluten allergy *
Lactose intolerance, food allergies, nutritional deficiency, or dietary restrictions *
Bladder or kidney problems *
Arthritis, scoliosis, limited use of arm and/or legs, muscle, joint or bone problems *
Artificial Joint *
Rash/hives, eczema or other skin problems *
Impaired vision, hearing or speech *
Developmental disorder, learning problems/delays, or intellectual disability *
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures *
Recurrent headaches/migraines, fainting or dizziness *
Hydrocephaly or placement of a brain shunt *
Behavioral, emotional, communication or psychiatric problems/treatment *
Diabetes, hyperglycemia, or hypoglycemia *
Thyroid or pituitary problems *
Anemia, sickle cell disease/trait, or other blood disorder *
Hemophilia, excessive bleeding, or easy bruising *
Transfusions or receiving blood products *
Infectious diseases (mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), MRSA, sexually transmitted disease (STD), or HIV/AIDS *
Cancer, tumors, other malignancies, chemotherapy, radiation therapy, or bone marrow/organ transplant *
History or family history of malignant hyperthermia, or adverse reactions to sedation and/or anesthesia *
Premedication(s) required by your physician *
In the past 12 months have you taken any of the following? *
Check all that apply
Is there any other significant medical history that the dentist should be made aware of? *
Females only
Taking contraceptives (birth control pill) or other forms of hormones
Pregnant, possibly pregnant or planning pregnancy
Dental History
Reason for your visit
How would you describe your oral health? *
Is their a family history of cavities? *
If yes, check all that apply:
Do you have a history of any of the following?
Mouth sores/fever blisters *
Bad Breath *
Bleeding gums *
Cavities/Decayed Teeth *
Injury to teeth, mouth and/or jaws *
Jaw joint problems (clicking, popping or locking, pain) *
Periodontal Disease *
How often do you floss? *
What kind of toothpaste do you use? Check all that apply. *
Do you whiten your teeth? *
Are your teeth sensitive? *
Are you on a special or restrictive diet? *
Do you have a diet high in sugar or starches? *
How frequently do you have the following?
Candy or other sweets *
Snacks between meals *
Soft drinks, sodas, juices, iced teas, or energy drinks *
Have you ever had orthodontic treatment? *
Are you apprehensive about dental treatment? *
Is there anything else we should know before your visit? *
To be completed at the office
Date of Appointment
Date of Appointment
To be completed at the office
Thank you for completing our new patient intake form, ages 18 and over.