Patient Intake Form Step 1 of 4 25% Basic DetailsPatient Name* First Last Home Address* Street Address Address Line 2 City Island / State / Province ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 HistoryPhysician* Office PhoneDate 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 OnlyWOMEN 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 HistoryDo 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 QuestionnaireDo 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*09/08/2024
