Serenity Family Dental of Burlington

Patient Intake Form
Email
Date
As required by law, our office 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. Please note that you will be asked some questions about your responses to this questionnaire, and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
PATIENT INFORMATION
Name

First NameMiddle initialLast Name
Home Phone
Cell Phone
Work Phone
Type a question
Address

Street Address

Street Address Line 2

CityState

Zip Code
Height
Weight
Date of Birth
Sex
Occupation
Emergency Contact
How did you hear about us?
If you are completing this form for another person, what is your relationship to that person?
Name
Relationship
Home Phone
Cell Phone
DENTAL INFORMATION
Are your teeth sensitive to cold, hot, sweets or pressure?
Do you have earaches or neck pains?
Does food or floss catch between your teeth?
Do you have any clicking, popping, or discomfort in the jaw?
Is your mouth dry?
Do you brux or grind your teeth?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Do you have sores or ulcers in your mouth?
Have you ever had any problems associated with previous dental treatment?
Do you wear dentures or partials?
Is your home water supply fluoridated?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Are you currently experiencing dental pain or discomfort?
Do you drink bottled or filtered water?
If you do drink bottled or filtered water, how often?
Chief Complaint
Date of your last dental exam
What was done at that time?
Date of last dental x-rays
Reason for visit
MEDICAL INFORMATION
Are you currently under the care of a physician?
Physician Name
Phone Number
Address / City / State / Zip
Are you in good health?
Has there been any change in your general health within the past year?
If yes, what condition is being treated?
Date of last physical exam
Do you have a history of chemical dependency?
Are you in recovery?
If yes, how long have you been in recovery?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?
If you had an orthopedic total joint (hip, knee, elbow, finger) replacement?, date
If you had an orthopedic total joint (hip, knee, elbow, finger) replacement?, have you had any complications?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
If yes, what was the illness or problem?
Do you take any blood thinners?
Do you take aspirin on a regular basis?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
If you are taking or had recently taken any prescription or over the counter medicine(s), please list all medications, including vitamins, natural or herbal preparations and/or diet supplements
Pregnant?
Number of weeks
Taking birth control pills or hormonal replacements?
Nursing?
ALLERGIES Please mark "Yes" if you are allergic to (or have had a reaction to) the following.
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal
Animals
Food / Other
If yes, please specify
Please mark "Yes" if you have (or have had) any of the following diseases or problems.
Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
If yes on Blood transfusion, date
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
Malnutrition
Gastrointestinal disease
GE Reflux / persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
If yes on Neurological disorders, please specify
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
If yes on Mental health disorders, please specify
Recurrent infections
If yes on Recurrent infections, please specify
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
STDs / STIs
Excessive urination
ADD
ADHD
Sensory Processing Disorder
Oral Sensory Sensitivity
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?
If you have any disease, condition, or problem not listed above that you think we should know about, please explain
PHARMACY INFORMATION
Pharmacy Name
Pharmacy Phone
Pharmacy Address
SIGNATURE
NOTE: Both the Doctor and the patient are encouraged to discuss any relevant patient health issues before treatment.
Name of Patient/Legal Guardian
Date
Signature of Patient/Legal Guardian

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Patient Intake Form

PATIENT INFORMATION

If you are completing this form for another person, what is your relationship to that person?

DENTAL INFORMATION

MEDICAL INFORMATION

ALLERGIES Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

PHARMACY INFORMATION

SIGNATURE