New Patient Intake/Health History Form
Patient legal name
*
First Name
Last Name
Patient chosen name
Gender patient identifies with
Male
Female
Other
Patient sex at birth
*
Male
Female
Patient preferred pronouns
She/Her
He/Him
They/Them
Other
Patient date of birth
*
-
Month
-
Day
Year
Date
Patient social security number
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
Patients with a BMI 45 or higher or a weight of 300 lbs or higher are not candidates for our office.
What language do you and the patient best understand?
*
Medicaid insurance
*
PA
NJ
Private Pay
Name of state medicaid insurance
*
Examples: Keystone First, Health Partners etc.
Insurance policy number
*
Does the patient have dental insurance provided by a family member's employer?
Yes
No
Name of employer based insurance
Examples: Delta Dental, MetLife, etc.
Insurance policy number
*
Insurance subscriber name
*
First Name
Last Name
Insurance subscriber social security number
*
Insurance subscriber date of birth
*
-
Month
-
Day
Year
Insurance subscriber relationship to patient
*
Referral obtained from
*
Please Select
Primary Care Physician
Dentist
Patient residence
*
Family Home
Permanent Supportive Housing
Name of permanent supportive housing program
*
Name of primary caregiver
*
First Name
Last Name
Primary caregiver phone number
*
Cell phone number preferred
Primary caregiver email
*
example@example.com
Name of legal guardian/person who signs consent
*
First Name
Last Name
Relationship to patient
Legal guardian phone number
*
Cell phone number preferred
Legal guardian email
*
example@example.com
Is the patient edentulous (without teeth)?
*
Yes
No
Date of last dental exam
*
-
Month
-
Day
Year
Date
Is the patient cooperative with the following dental care? Check all that apply.
*
Exam
Cleaning
X-rays (please provide most recent)
Is the patient currently experiencing dental pain or discomfort?
*
Yes
No
Not sure
Does the patient's gums bleed when brushing or using dental floss?
*
Yes
No
Not sure
Does the patient have earaches or neck pains?
*
Yes
No
Not sure
Has the patient ever had orthodontic (braces) treatment?
*
Yes
No
Not sure
Has the patient had their wisdom teeth removed?
*
Yes
No
Not sure
What year were their wisdom teeth removed?
*
Does the patient brux or grind their teeth?
*
Yes
No
Not sure
Does the patient have sores or ulcers in their mouth?
*
Yes
No
Not sure
Does the patient wear dentures or a partial?
*
Yes
No
Not sure
Has the patient ever had a serious injury to their head or mouth?
*
Yes
No
Not sure
Please indicate if you have or have not had any of the following diseases or problems
*
Yes
No
Not Sure
Abnormal bleeding
Adrenal Disease
AIDS or HIV infection
ALS
Anemia
Angina
Aortic Stenosis
Arrhythmia
Arteriosclerosis
Arthritis
Artificial (prosthetic) heart valve
Asthma
Atrial Septal Defect
Autoimmune disease
Blood transfusion
Bronchitis
Cancer/Chemotherapy/Radiation Treatment
Cardiovascular disease
CHD: Repaired (completely) in last 6 months
CHD: Repaired CHD with residual defects
Chest pain upon exertion
Chiari Malformation
Chronic Aspiration
Chronic or recent Acute Pancreatitis
Chronic pain
Congenital heart disease (CHD): Unrepaired, cyanotic CHD
Congestive heart failure
Coronary Artery Disease
Damaged heart valves
Damaged valves in transplanted heart
Deep brain stimulator
Diabetes Type I or II
Dialysis
Eating disorder
Emphysema
Excessive urination
G.E. Reflux/persistent heartburn
Gastrointestinal disease
Glaucoma
Heart attack
Heart murmur
Hemophilia
Hepatitis, jaundice or liver disease
High blood pressure
Huntington’s Disease
Insulin pump
Kidney problems
Low blood pressure
Malnutrition
Mental health disorders
Mitochondrial disease
Mitral valve prolapse
Multiple Sclerosis
Myotonic Dystrophy
Neurological disorder
Night sweats
Osteoporosis
Other congenital heart defects
Pacemaker
Persistent swollen glands in neck
Pituitary disease
Pneumonia in past three months
Previous ineffective endocarditis
Pulmonary Hypertension
Recurrent Infections
Rheumatic fever
Rheumatic heart disease
Rheumatoid arthritis
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Sickle Cell Disease
Sinus trouble
Sleep disorder
Stroke
Systemic lupus erythematosus
Thrombocytopenia
Thyroid problems
Tracheostomy
Tuberculosis
Tubuerous Sclerosis
Ulcers
Ventricular Septal Defect
VNS Implant
Von Willebrand Disease
List all medical diagnosis/conditions
*
Example: IDD, Down Syndrome, etc.
List any allergies and reactions
*
List all current medications including vitamins, supplements, THC, CBD, weekly or monthly injections
*
If preferred, you can attach a medication list at the end of this form
How are oral medications administered?
*
Has the patient been hospitalized in the past year?
*
Yes
No
If yes, when? and what was the illness or problem?
*
Please attach documentation from hospitalization
List any surgeries/operations and what year performed
*
Does the patient see any Specialty Health Care Provider(s)? Please list the type of specialty, and date of last visit
*
Examples: Cardiologist, Neurologist, etc.
Has the patient ever had general anesthesia?
*
Yes
No
Has the patient or any family member had any complications with general anesthesia?
Does the patient have seizures?
*
Yes
No
Date of last seizure
*
-
Month
-
Day
Year
Date
Any anti-seizure medication changes in the last 2 months?
*
Yes
No
Does the patient have a CPAP machine?
*
Yes
No
Is there anything else you want our dentists and anesthesiologists to know?
Please attach any relevant documentation such as Lifetime History, referral, or any recent hospitalization records.
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