NEW PATIENT INTAKE FORM

Medical history

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

Have you recently, or are you presently taking any prescription/non-prescription medications?

Yes
No

please list all prescription/non prescription medicationsP

Do you experience dry mouth with or without medication?*

Yes
No

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

Yes
No

Please explain

Do any of the following conditions apply to you?

Additional condition details

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

+ Increased
- Decreased
No

Please explain by how much?

Do you follow a special diet?*

Yes
No

Please explain

Do you smoke?*

Yes
No

How much?

Do you vape?*

Yes
No

How much?

Which of these materials are you allergic to?

Acrylic
Latex
Metal
None

Please specify any allergies

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

Yes
No

When did you last have radiation or chemotheraphy?

Do you have hearing or memory issues where you may need extra assistance?

Yes
No

Do you have any of the following illnesses?

Please list other serious illnesses

Is there anything else the denturists should know about your health?

Step 1 of 3 - Patient Information

MEDICAL UPDATE FORM

Patient information

Primary insurer

Secondary insurer

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Consent