Patient Intake Form Step 1 of 2 50% Patient Name First Last Patient Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Patient PhonePatient Birth DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Email GenderGenderMaleFemaleOccupation Martial StatusSelect From Drop DownSingleMarriedSeparatedDivorcedWidowedSpouse's Name First Last Relationship to Patient (if other than self) Address (if different from patients) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home or Cell Phone (if differnt from patient)Primary Insurance Company Insurance Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employee with Insurance Employer Relationship to Patient Please confirm* I understand that payment is my obligation regardless of insurance or any other third party involvement. Personal Physician Name First Last Have you been hospitalized within the past 2 years?Choose From Drop DownYesNoIf yes, for what? Are you currently being treated by a physician?Choose From Drop DownYesNoIf yes, for what? Are you currently taking medication or drugs?Choose From Drop DownYesNoIf yes, for what? Have you ever received counseling for excessive use of alcohol and/or prescription drugs?Choose From Drop DownYesNoAre you allergic to any medication?Choose From Drop DownYesNoWhat medications? Answer "yes" or "no" to the following:Do you bleed excessively upon injury? Yes No Are you pregnant? Yes No Have you ever been involved with dental medical legal activity? Yes No Are you allergic to latex? Yes No Are you allergic to any metals? Yes No Have you ever had a skin rash or other reaction to metal jewelry? Yes No Place a mark to indicate if you have had any of the following: A. AIDS B. Arthritis C. Asthma D. Cancer E. Diabetes F. Epilepsy G. Glaucoma H. Heart Murmur I. Heart Problems J. Hepatitis K. High Blood Pressure L. Jaundice M. Kidney Problems N. Low Blood Pressure O. Nervous Breakdown or Psychiatric Therapy P. Rheumatic Fever Q. Stroke R. Sexually Transmitted Diseases S. Tuberculosis T. Other Diseases If you checked for either I or T please describe: Former Dentist First Last City of Former Dentist City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Reason for todays visit Date of Dentist Visit Date of Last X-rays Place a mark to indicate if you have had any of the following: Bad breath Bleeding gums Blisters on lips or mouth Burning sensation on tonque Chew on one side of mouth Cigarette, pipe or cigar smoking Clicking or popping jaw Dry mouth Fingernail biting Found collection between teeth Foreign objects Grinding teeth Gums swollen or tender Jaw pain or tiredness Lip or cheek biting Loose teeth or broken fillings Mouth breathing Mouth pain while brushing Orthodontic treatment Pain around ear Periodontal treatment Sensitivity to cold Sensitivity to heat Sensitivity to sweets Sensitivity when biting Sore or growth in your mouth How often do you floss?DailyWeeklyMonthlyI don'tHow often do you brush your teeth?3+ times a day3 times a day2 times a day1 time a dayWeekly
