New Patient - Health History

Help us know more about your dental history, so we can assist you in the best manner possible!
Date

DayMonthYear
Date
Name

First NameLast Name
Gender
Age
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Welcome To Health Chakra!
As required by law, Health Chakra adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. This information is vital to allow us to provide appropriate care for you. Health Chakra does not use this information to discriminate.
Are you currently experiencing dental pain or discomfort?
What is the date of your last dental visit? (Estimate if needed)

MonthDayYear
Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:
If you feel your smile is less than ideal, how does this affect you?

Other
How do you think having a wonderful smile would change your life? (Check all that apply)

Other
What would you like to change about your smile? (Check all that apply)

Other
Have you ever had any of the following in the last 3 years? (Check all that apply)
What are some of your habits or environmental conditions that may affect your mouth? (Check all that apply)
Do you have any other comments or concerns you would like to discuss?
Should be Empty:

Help us know more about your dental history, so we can assist you in the best manner possible!