Dental intake

Dental history, current concerns, and anxiety level for the first appointment.

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Welcome to your dental visit

Full name*

First Name

Last Name

Date of birth*

Phone number*

Email address

Last dental visit

An estimate is fine.

Main reason for your visit*

Cleaning & check-up Pain or discomfort Cosmetic dentistry Orthodontic consultation Other:

Have you noticed any of the following?

Sensitivity to hot or cold Gums that bleed when brushing Grinding or clenching teeth Persistent bad breath Loose or broken teeth Jaw pain or clicking

How anxious does visiting the dentist make you?

Not at all

1 2 3 4 5 6 7 8 9 10

Very anxious

It helps us make your visit more comfortable.

Current medications and allergies

Include any anesthetics or antibiotics you've reacted to.

Relevant medical conditions

Diabetes Heart condition High blood pressure Pregnancy Taking blood thinners None

Mental Health Intake Form Healthcare Mental Health Journal Healthcare Mental Health Progress Notes Healthcare Mental Health Questionnaire Healthcare

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