New Dental Patient Intake | Burke Mountain Denture Clinic

DENTAL INTAKE FORM
Patient Information
Name*
First Last
Date of birth
YYYY dash MM dash DD
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Who may we thank for referring you?
Family physician name
First Last
Phone
Emergency contact name
First Last
Phone
Medical History
Are you currently seeing a physician for treatment of a recent or ongoing medical condition?
- Yes
- No
Recent or ongoing medical condition information
Have you had a serious illness or operation within the last year?
- Yes
- No
Serious illness or operation information
Have you ever had an allergic reaction to a drug?
- Yes
- No
Allergic reactions to drugs information
Do you smoke?
- Yes
- No
How much do you smoke?
List any current medications
Name of drug Dosage Frequency
Check the medical conditions that apply to you
- Presently in good health
- Artificial joints or stents
- Chest pain
- Cuts in your skin stay open a long time
- Prolonged Bleeding
- Abnormal bleeding/hemophilia
- Allergies
- Anemia
- Arthritis
- Bone disorders
- Asthma/hayfever
- Congenital heart defect
- Heart Murmur
- Heart Attack
- Heart surgery
- Pacemaker
- COPD
- Diabetes
- Dizziness
- Stroke
- Epilepsy
- Hepatitis/Liver problems
- Gastrointestinal disorders
- Herpes (cold sores)
- Nervous Disorders
- Pneumonia
- High Blood Pressure
- Radiation/Chemotherapy
- Tumor or Cancer
- Rheumatic Fever
- Tuberculosis
- Taken medication to strengthen your bones
- Other
Other medical conditions
Gender at birth
- Male
- Female
Please check the following that apply to you
- Taking Oral Contraceptives
- Pregnant
- Nursing
Dental History
Check the dental conditions that apply to you
- You are a mouth breather
- Your teeth or jaw feels uncomfortable when you awake in the morning
- You are aware of your jaw clicking or popping
- You have been told that you grind your teeth
- You have "tension" headaches
- You are under an abnormally high amount of stress
- You sleep well
- You have sleep apnea
- You have been advised to take antibiotics prior to a dental appointment
- Other
Other dental conditions
Have you ever had orthodontic or invisalign treatment?
- Yes
- No
Are you happy with the appearance of your teeth?
- Yes
- No
If no, what would you change?
The name of your previous dentist or dental clinic
Would you like us to contact them to have your most recent x-rays forwarded to our clinic?
- Yes
- No
Authorization
Consent*
I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my Dentist, previous Denturist or Physician being contacted if necessary, as further dental/medical information may be required for my dental care. I, the undersigned, hereby consent to the performing of the preventative dental procedures. I, the undersigned, am aware that the whole amount of treatment is due to be paid by me and understand any direct billing to my insurance plan that comes back unpaid is to be paid promptly by me.*
Patient signature*
Name
This field is for validation purposes and should be left unchanged.

Name of drug	Dosage	Frequency

DENTAL INTAKE FORM

Patient Information

Medical History

Dental History

Authorization