Are you a full-time student at a college?
Yes
No
Marital Status:
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Full Name
First Name
Last Name
Relationship
Phone Number
Address
Do you have a personal physician?
Yes
No
Full Name
First Name
Last Name
Address
Date of Last Visit
-
Month
-
Day
Year
Date
Phone Number
Are you currently under the care of a physician?
Yes
No
Do you use tobacco in any form?
Yes
No
Do you have any artificial joints or implants?
Yes
No
Do you have any allergies?
Yes
No
Are you taking any birth control pills?
Yes
No
Are you nursing?
Yes
No
Are you pregnant?
Yes
No
#weeks
Do you have any disease, condition or problem
Your current dental health is
Good
Fair
Poor
Are your teeth sensitive to heat, cold or anything else?
Yes
No
Do you take fluoride supplements?
Yes
No
Have you ever had a serious/difficult problem with any previous dental work?
Yes
No
Have you ever had any unfavorable dental experiences?
Yes
No
Are you apprehensive about dental treatment?
Yes
No
Do you gag easily?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Are you currently in pain?
Yes
No
Do you now or have you had any pain/discomfort in your jaw joint?
Yes
No
Are you aware of clenching or grinding your teeth?
Yes
No
Does it hurt when you chew or open wide to take a bite?
Yes
No
Do you have any jaw symptoms or headaches upon waking up in the morning?
Yes
No
Do you have pain in the face, cheeks, jaw, joints, throat or temples?
Yes
No
Do you like your smile?
Yes
No
Is there anything you would like to change about your smile?
Yes
No
Are you happy with the color of your teeth?
Yes
No
Have you ever had gum disease?
Yes
No
Do your gums bleed?
Yes
No
Have you ever had a deep cleaning or scaling and root planing?
Yes
No
Date
-
Month
-
Day
Year
Date
brush/day
Date
-
Month
-
Day
Year
Date
floss/week
Is there any specific service and/or concern you would like to inquire about?
How can we accommodate you better during your dental visit?
How may we help you today?
If yes, please list
Are you taking any medication? If yes, please list each one
Please check your preferred method of contact for appointment confirmation
E-mail
Cell Phone
Work Phone
Home Phone
If yes, name of college
Cell Phone
Work Phone
Address
Occupation
Patient E-Mail
example@example.com
Patient Gender
Please Select
Male
Female
N/A
Patient Name
*
First Name
Last Name
Patient Birth Date
-
Month
-
Day
Year
Date
How did you hear about our office?
Age
Gender Pronoun
Full Name
*
First Name
Last Name
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date
*
-
Month
-
Day
Year
Date
Signature
*
Signature
*
Should be Empty: