Sample Dental Intake Questionnaire

Name

Date of Birth

Street Address

City

State

Zip

Telephone

Email

Cellular

Are you under medical treatment now?

Are you taking any medications including non-prescription?

If yes, what medications are you taking?

Are you allergic to any drugs of medication?

If yes, what drug or medication?

Are you taking aspirin or blood thinners at this time?

Do you have or have had any of the following?  High Blood Pressure?  Heart Attack? Asthma? Epilepsy? Diabetes? Hepatitis? Joint Replacement or Implant?  Liver Disease? Tuberculosis? Anemia? Hemophilia? Other?

Do you feel pain to any of your teeth?

Date of last Dental Examination?

How would you describe your current dental problem?

Do you have any fear of dental work?

Anything else?

Do you have a emergency contact for us that we can reach in the event of a emergency?