Medical Intake form

Patient's Name

First NameLast Name
Date

MonthDayYear
Date
Driver's License #
Patient's Name

First NameMiddle NameLast Name
Person Filling Out This Form (if the patient is a minor)

First NameMiddle NameLast Name
Relationship to the Patient
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Person Responsible for Payment

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
SSN/INS ID:
Gender
Marital Status
Employer
Occupation
Home Number
Work Phone
Patient's Spouse Name

First NameMiddle NameLast Name
Spouse's Employer
Occupation
Work Phone
DENTAL INSURANCE INFORMATION
Patient's, Parent's or Guardian's Signature:
Insured's Name
Insured's Date of Birth

MonthDayYear
Date
Insured's Address (If different from above)

Street Address

Street Address Line 2

CityState

Zip Code
Insured's Social Security
Insured's Employer
Insurance Company Name
Group # and Member ID#
Insurance Address and Phone #
EMERGENCY INFORMATION
Local Friend or Relative not living with you
Complete Address
Phone Number
PRIVACY POLICY

I have chosen NOT to receive a copy of the privacy policy. I understand a copy is available. Please refer to the link below.
Link to NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
CONSENT FOR TREATMENT

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a through diagnosis of my dental needs.

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary, I fully understand that using anesthetics, sedatives and other medication as necessary, I fully understand that using anesthetic agents embodies certain risks, I understand that I can ask for a complete recital of any possible complications.

4. I give consent to the doctor's or designated staff's use and disclosure of any oral, written, printed or electronic records that are individually identifiable as mine for the purpose of carrying out treatment, payment, education, promotion and health care operations.
Patient's, Parent's or Guardian's Signature:
GETTING TO KNOW YOU
Source of Referral
Whom may we thank for referring you?
Is another member of your family or relative a patient in our practice?
PRIVACY POLICY

I have chosen NOT to receive a copy of the privacy policy. I understand a copy is available at any time on the website: www.walnutcreek.net/forms
Date

MonthDayYear
Patient's, Parent's or Guardian's Signature:

Clear

DENTAL HISTORY

	Excellent	Good	Fair	Poor
How would you rate the condition of your mouth?

Previous Dentist
How long have you been a patient?
Months/Years
Date of most recent dental exam

MonthDayYear
Date of most x-rays

MonthDayYear
Date of most recent treatment other than cleaning

MonthDayYear
I routinely see my dentist every:
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY

Yes No

1. Are you fearful of dental treatment?
Scale of 1 to 10

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Most

	Yes	No
1. Are you fearful of dental treatment?

	Yes	No
2. Have you ever had an unfavorable dental experience?
3. Have you ever had complications from past dental treatment?
4. Have you ever had trouble getting numb or reactions to local anesthetic
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

GUM AND BONE

	Yes	No
7. Do your gums bleed or are they painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth
9. Have you ever noticed an unpleasant taste or odor in your mouth?
10. Is there anyone with a history of periodontal disease in your family?
11. Have you ever experienced gum recession?
12. Are your teeth becoming loose on their own (without an injury), or do you have difficulty eating an apple?
13. Have you ever experienced a burning sensation in your mouth?

TOOTH STRUCTURE

	Yes	No
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth ever feel too little or do you have difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets or avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth or had a toothache or cracked filling?
20. Do you frequently get food caught between any teeth?

BITE AND JAW JOINT

	Yes	No
21. Do you have problems with your jaw join? (pain, sounds, limited opening, locking or popping)
22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
23. Do you/ would you have any problems with chewing bagels, baguettes, protein bars or other hard food?
24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
25. Are your teeth becoming more crooked, crowded, or overlapped?
26. Are you teeth developing spaces or becoming more loose?
27. Do you have trouble finding you bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench or grind your teeth together in the daytime or make them sore?
31. Do you have any problems with sleep or wake up with an awareness of your teeth?
32. Do you wear or have you ever worn a bite appliance?

SMILE CHARACTERISTICS

	Yes	No
33. Is there anything about the appearance of your teeth that you would like to change?
34. Have you ever whitened (bleached) your teeth?
35. Have you ever felt uncomfortable or self-conscious about the appearance of your teeth?
36. Have you been disappointed with the appearance of previous dental work?

Patients Signature

Clear
Date

MonthDayYear
Patient's Name
Age
Name of Physician/and their specialty
Most recent physical examination

MonthDayYear
Purpose
What is your estimate of your general health?
HAVE YOU EVER HAD THE FOLLOWING:

Yes No

1. hospitalization for illness or injury
2. allergic reaction to:

aspirin, ibuprofen, acetaminophenpenicillinerythromycincodeinelocal anestheticfluoridemetals (gold, stainless steel)latexany other medications ____________________________________

	Yes	No
1. hospitalization for illness or injury

	Yes	No
3. heart problems or cardiac stent (within last 6 months)
4. history of infective endocarditis
5. artificial heart valve, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. orthopedic implant (joint replacement)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR>3.5)
13. emphysema, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (i.e. snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes
24. stomach or duodenal ulcer
25. digestive disorders (i.e. gastric reflux)
26. osteoporosis/osteopenia (taking bisphosphonates)
27. arthritis
28. glucoma
29. contact lenses
30. head or neck injuries

	Yes	No
31. epilepsy, convulsions (seizures)
32. neurological problems (attention deficit disorder)
33. viral infections and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. STD / HPV / STI
37. hepatitis
38. HIV / AIDS
39. tumor, abnormal growth
40. radiation therapy
41. chemotherapy
42. emotional problems
43. psychiatric treatment
44. antidepressant medication
45. alcohol / drug dependency
46. presently being treated for other illness
47. aware of any change in your general health
48. taking medication for weight management
49. taking dietary supplements
50. often exhausted or fatigue
51. experiencing frequent headaches
52. a smoker or smoked previously
53. considered a touchy / sensitive person
54. often unhappy or depressed
55. easily upset or irritated
56. FEMALE: taking birth control pills
57. FEMALE: pregnant
58: MALE: prostate disorders

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment
List any medications, supplements, and or vitamins taken within the last two years
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR MEDICATIONS YOU MAY BE TAKING.
Patient's Signature

Clear
Date

MonthDayYear
DOCTOR'S SIGNATURE:FOR OFFICE USE ONLY DATE:FOR OFFICE USE ONLY
Should be Empty:

DENTAL INSURANCE INFORMATION

EMERGENCY INFORMATION

GETTING TO KNOW YOU

PLEASE ANSWER YES OR NO TO THE FOLLOWING: