Medical - Dental Intake Form
Appointment times will be available once all required fields are completely filled out. Required fields are denoted with *
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Male
Female
Date of Birth
Address
Address 2
Prov./State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If Referred, please provide name of person/business.
Emerg. Contact First Name
Emerg. Contact Last Name
Emerg. Relation
Phone
1. Are you being treated for any medical condition at present or within the past 2 years?
Yes
No
If Yes, Please Explain
Physician
Phone #
2. Have you been hospitalized in the past 2 years?
3. When was your last visit to a Physician
Last complete physical examination?
4. Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs? Please List
5. Have you ever reacted adversely to any medication?
6. Have you ever been advised against taking any specific type of medication?
7. Do you have any other allergies?
8. Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?
Yes
No
If so, please explain.
9. Has any family member had diabetes?
10. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?
11. Do your ankes, feet or hands swell?
12. Has your weight, appetite or energy level changed dramatically recently?
13. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
14. Do you follow a special diet?
15. Have you tested HIV positive?
16. Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections
17. Have you ever had any injury or surgery to your face or jaws?
18. Do you wear eyeglasses or contact lenses?
19. Do you have any hearing difficulties?
20. Do you smoke or use any other forms of tobacco?
Are you wearing the tranasdermal nicotine patch?
21. Are you alcohol and/or drug dependent?
and, Have you received treatment?
INDICATE ANY PRESENT OR PAST CONDITIONS
A.I.D.S.
Anemia
Angina pectoris
Arthritis/rheumatism
Artificial heart valve
Artificial joints(hip, knee)
Blood disorders
Bronchitis
Cancer
Circulation Problems
Congenital heart lesions
Cortizone/steroid
Diabetes
If diabetic,
Type I
Type II
If diabetic, what is your HbA1c?
Emphysema
Epilepsy or seizures
Fainting or dizzy spells
Glandular disorders
Glaucoma
Head/neck injuries
Heart disease or attack
Heart murmur
Heart pacemaker
Heart rhythm disorder
Heart surgery
Hepatitis A B C
Herpes
High blood pressure
Low blood pressure
Hodgkins disease
Hyperglycemia
Hypoglycemia
Jaundice
Kidney disease
Liver disease
Lung disease
Lupus
Malignant Hyperthermia
Mental/nervous disorder
Mitral valve prolapse
Organ transplant/medical implant
Psychiatric treatment
Radiation treatment/chemotherapy
Rheumatic/Scarlet fever
Sickle cell disease
Sinus trouble
Stomach/intestinal problems/Ulcers
Stroke
Thyroid disease
Tuberculosis
Venereal Disease
Other
Recent Conditions (Please indicate Date)
Measles
Date
Mumps
Date
Chicken Pox
Date
Strep Throat
Date
Tonsillitis
Date
WOMEN ONLY
Are you pregnant or suspect you may be?
If yes, what is the expected delivery date?
Are you taking any birth control pills?
Other
Do you currently have, or have you had in the past, any disease, condition or problem not listed above?
If yes, please specify
Do you wish to speak privately about any problem or medical condition?
Dental History
Is there a dental problem you would like treated immediately
If so, please describe
Date of your last dental visit
Date of your last dental cleaning
Date of your last x-rays
1. Have you been seeing a dentist regularly?
2. Have you ever had any of the following
Periodontal Treatement? (treatment of the gums)
Orthodontic Treatment? (to straighten or realign teeth)
A bite plate or any other appliance?
Your bite adjusted or teeth ground?
Oral Surgery? (surgery in or about the mouth/jaw joint or implant surgery)
If you have had Oral Surgery, who performed the surgery and when?
Are you being followed up by a dental specialist?
Current Conditions
3. Are there any growths or sore spots in your mouth?
4. Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums?
5. Have you noticed any loose teeth, or have any of your teeth shifted?
6. Does food catch between your teeth?
7. Are any of your teeth sensitive to heat, cold, sweets or pressure?
8. Have you been advised to take antibiotics before a dental appointment?
9. Do you use dental floss, proxabrush or stimudents?
If so, which and how often?
10. How often do you brush your teeth?
Do you feel that you have bad breath?
Have you ever experienced any of the following:
Popping/clicking on your jaw joints?
Pain in your jaw joints, around your ear, or side of your face?
Difficulty in opening or closing?
Pain when teeth are clenched?
Pain or difficulty while chewing?
Do you have any of the following habits?
Clenching or grinding your teeth while awake or asleep?
Biting your cheeks or lips?
Mouth breathing while awake or asleep?
Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?
Concerns
Do you have any emotional concerns about having dental treatment?
Are you unhappy with the appearance of your teeth?
and, What would you like to see changed?
have you ever had an upsetting experience in a dental office. or any complications during of following dental treatment, any questions/concerns?
If so, please specify