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Patient Intake Form

The Patient Intake Form helps you share important details before your dental appointment. By providing your dental history, current medications, and personal information, you’ll assist your dentist in preparing for a comprehensive and personalized treatment. This form ensures that your visit is efficient and focused on your specific dental needs.

Patient Intake Form

"*" indicates required fields

Step 1 of 4

25%

Basic Details

Patient Name*

First Last

Home Address*

Street Address Address Line 2 City Island / State / Province ZIP / Postal Code Country

Gender*

Male

Female

Date of Birth*

MM slash DD slash YYYY

Email Address*

Employer

Insurance Company

Home Phone*

Cell Phone*

Business Phone

Patient Medical History

Physician*

Office Phone

Date of Last Exam

MM slash DD slash YYYY

Are you under medical treatment now?*

Yes

No

Have you ever been hospitalized for any surgical operation or serious illness?*

Yes

No

Are you taking any medication(s) including non-prescription medicine?*

Yes

No

If yes, what medication(s) are you taking?

Have you ever taken Fen-Phen/Redux?*

Yes

No

Do you use tobacco?*

Yes

No

Do you use alcohol, cocaine or other drugs?*

Yes

No

Are you wearing contact lenses?*

Yes

No

Are you allergic to or have you had any reactions to the following?

Local anesthetics (eg. nococaine)*

Yes

No

Penicillin or other antibiotics*

Yes

No

Sulfa drugs*

Yes

No

Barbiturates*

Yes

No

Sedatives*

Yes

No

Iodine*

Yes

No

Aspirin*

Yes

No

Any other allergic reactions?

Women Only

WOMEN ONLY: Are you pregnant or think you may be pregnant?*

Yes

No

WOMEN ONLY: Are you nursing?*

Yes

No

WOMEN ONLY: Are you taking birth control pills?*

Yes

No

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?*

Yes

No

Do you have any of the following?

High Blood Pressure*

Yes

No

Heart Attack*

Yes

No

Rheumatic Fever*

Yes

No

Swollen Ankles*

Yes

No

Fainting / Seizures*

Yes

No

Asthma*

Yes

No

Low/High Blood Pressure*

Yes

No

Epilepsy / Convulsions*

Yes

No

Leukemia*

Yes

No

Diabetes*

Yes

No

Kidney Diseases*

Yes

No

AIDS or HIV Infection*

Yes

No

Thyroid Problem*

Yes

No

Heart Disease*

Yes

No

Cardiac Pacemaker*

Yes

No

Heart Murmur*

Yes

No

Angina*

Yes

No

Frequently Tired*

Yes

No

Anemia*

Yes

No

Emphysema*

Yes

No

Cancer*

Yes

No

Arthritis*

Yes

No

Joint Replacement or Implant*

Yes

No

Hepatitis / Jaundice*

Yes

No

Sexually Transmitted Disease*

Yes

No

Stomach Troubles / Ulcers*

Yes

No

Chest Pains*

Yes

No

Easily Winded*

Yes

No

Stroke*

Yes

No

Hay Fever / Allergies*

Yes

No

Tuberculosis*

Yes

No

Radiation Therapy*

Yes

No

Glaucoma*

Yes

No

Recent Weight Loss*

Yes

No

Liver Disease*

Yes

No

Mitral Valve Prolapse*

Yes

No

Respiratory Problems*

Yes

No

Any others?

Patient Dental History

Do your gums bleed while brushing or flossing?*

Yes

No

Are your teeth sensitive to hot or cold liquids/foods?*

Yes

No

Are your teeth sensitive to sweet or sour liquids/foods?*

Yes

No

Do you feel pain to any of your teeth?*

Yes

No

Do you have any sores or lumps in or near your mouth?*

Yes

No

Have you had any head, neck or jaw injuries?*

Yes

No

Have you ever experienced any of the following problems in your jaw?

a) Clicking?*

Yes

No

b) Pain (joint, ear, side of face)?*

Yes

No

b) Difficulty in opening or closing?*

Yes

No

d) Difficulty in chewing?*

Yes

No

Do you have frequent headaches?*

Yes

No

Do you clench or grind your teeth?*

Yes

No

Do you bite your lips or checks frequently?*

Yes

No

Have you ever had any difficult extractions in the past?*

Yes

No

Have you had any orthodontic treatment?*

Yes

No

Have you ever had any prolonged bleeding following extractions?*

Yes

No

Have you ever had instruction on the correct method of brushing your teeth?*

Yes

No

Have you ever had instructions on the care of your gums?*

Yes

No

COVID-19 Questionnaire

Do you have any cold/flu like symptoms?*

Yes

No

Do you have a fever?*

Yes

No

Do you have a cough?*

Yes

No

Do you have a sore throat?*

Yes

No

Have you had loss of taste?*

Yes

No

Have you had diarrhea within the last fourteen days?*

Yes

No

Have you had exposure to any positive case of COVID-19?*

Yes

No

Have you worked in an environment with person(s) having tested positive for COVID-19?*

Yes

No

Terms & Conditions

I certify that I have read and understand the above information, to the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

Signature*

12/21/2024

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Preventive Dentistry
Cosmetic Dentistry
Wisdom Teeth Removal
Clear Ortho Aligners
Root Canals
Dentures
Braces
Sedation
Oral Surgery

About Us
Procedures
Oriel
Contact Us

About Us
Procedures
Oriel
Contact Us

Preventive Dentistry
Cosmetic Dentistry
Wisdom Teeth Removal
Clear Ortho Aligners
Root Canals
Dentures
Braces
Sedation
Oral Surgery

Preventive Dentistry
Cosmetic Dentistry
Wisdom Teeth Removal
Clear Ortho Aligners
Root Canals
Dentures
Braces
Sedation
Oral Surgery

About Us
Procedures
Oriel
Contact Us

About Us
Procedures
Oriel
Contact Us

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