FIRST VISIT-intake form step

Salutation

Mr. Mrs. Ms. Dr.

Registering for a child?

Yes No

I prefer appointment reminders by

Phone SMS (TEXT) Email

Are any other members of your family patients at our practice?

Yes No

Insurance Status

Yes, insurance applies to me No, insurance does not apply to me

Are you being treated for any medical condition at the present or any time within the past year?

Yes No Not Sure/Maybe

Has there been any change in your general health in the past year?

Yes No Not Sure/Maybe

Are you taking any prescription, non-prescription medications, or herbal supplements?

Yes No Not Sure/Maybe

Do you have any allergies?

Yes No Not Sure/Maybe

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes No Not Sure/Maybe

Do you have or have you ever had asthma?

Yes No Not Sure/Maybe

Do you have or have you ever had any heart or blood pressure problems?

Yes No Not Sure/Maybe

Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?

Yes No Not Sure/Maybe

Do you have a prosthetic or artificial joint?

Yes No Not Sure/Maybe

Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?

Yes No Not Sure/Maybe

Have you ever had hepatitis, jaundice, or liver disease?

Yes No Not Sure/Maybe

Do you have a bleeding problem or bleeding disorder?

Yes No Not Sure/Maybe

Have you ever been hospitalized for any illnesses or operations?

Yes No Not Sure/Maybe

Do you have, or have ever had any of the following? Please check

Are there any conditions/diseases not listed that you have or have had?

Yes No Not Sure/Maybe

Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?

Yes No Not Sure/Maybe

Do you smoke or chew tobacco products?

Yes No Not Sure/Maybe

Are you nervous during dental treatment?

Yes No Not Sure/Maybe

For women only: Are you pregnant or breastfeeding?

Yes No Not Sure/Maybe

How often do you see the dentist?

Not Applicable Every 3 months Every 4 months Every 6 months

Have you ever whitened (bleached) your teeth?

Yes No Not Sure/Maybe

I agree to receive emails with related information and updates.