New Patient Intake

Getting To Know You

Getting To Know You

Patient Registration and Health History New
A warm welcome, in order to provide you with optimum dental care we require a thorough medical and dental history which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer each question on All of this questionnaire.



Are you in Good Health? *
Do you smoke? *
Have you ever had a serious illness, operation, or hospitalization? *
Are you now under the care of a physician for any ongoing treatment or therapy?. *
Are you now taking any medicine, drugs, or pills? *
Do you have any allergies? *
Do you, or has any member of your family had diabetes? *
Do you have any blood disorders or do you bleed excessively? *
Have you ever had injury, surgery, or X-ray therapy to face or jaws? *
Do you have a tendency to faint? *
Do you have frequent severe headaches? *
Are you on a special diet? *
Do you have a prosthetic implant? (i.e. hip?) *


Do you see a dentist on a routine basis? *
Are you having pain at this time? *
Have you noticed any loosening of your teeth? *
Does food tend to become caught between your teeth? *
Do you suffer from pain and/or swelling of your gums? *
Do your gums often bleed when you brush your teeth? *
Do you feel nervous about having dental treatment? *
Have you ever had an upsetting experience in a dental office? *
Is it important to keep your teeth? *
Are you dissatisfied with the appearance of your teeth? *
Is there anything else about having dental treatment that bothers you? *
Insurance companies now only allow for "functionally acceptable work", whereas, in the past their coverage was for "quality work". It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. What is important to you? (Check one) *