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 memory issues?

Yes
No

Do you wear hearing aids?

Yes
No

Do you have a hearing aid practitioner or service provider?

Yes
No

Do you have cochlear implants?

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