NEW PATIENT INTAKE FORM

Medical history

Do you have a family physician?*

Yes
No

Name

First Last

Phone

Do you have a dentist?*

Yes
No

Name

First Last

Phone

Are you being treated for any medical conditions at present or within the past 5 years?

Yes
No

Please explain:

Have you been injured or hospitalized in the last 2 years?

Yes
No

Please explain:

Are you presently taking any prescription/non-prescription medications?

Yes
No

Please list your medications or write "NONE" in the box. **If you have a long list, please bring it to your appointment.

Do you experience dry mouth with or without medication?*

Yes
No

Which of the medical conditions apply to your family history?

Diabetes
Heart disease
Cancer
Osteoporosis
None

Have you ever had head, facial, jaw or neck trauma?*

Yes
No

Do any of the following conditions apply to you?

Additional condition details:

Has your weight, appetite, or energy level changed dramatically recently?*

Yes
No

Do you follow a special diet?*

Yes
No

Do you smoke?*

Yes
No

How much do you smoke?

Are you allergic to any of the following?

Acrylic
Latex
Metal
None

Please specify any other allergies:

Have you ever had or are going through radiation or chemotherapy?*

Yes
No

When was your last radiation or chemotheraphy treatment?

Do you have hearing issues?

Yes
No

Do you have memory issues?

Yes
No

Do you have any of the following?

Please list other illnesses:

Is there anything the denturists should know about your health?

Step 1 of 4 - Patient Information

NEW PATIENT INTAKE FORM

Patient information

Insurance information

Primary insurer

Secondary insurer

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Denture/Dental History

NEW PATIENT INTAKE FORM

Consent