Dental Assessment Form

Name(required)

Date of Birth(required)

Age(required)

Home Address(required)

Mobile Number(required)

Email Address(required)

My last physical examination was on (approximate):

Physician's Name:

Have you been under the care of any physician in the past 5 years? (required)

Yes

No

If yes, what is the condition being treated?

Are you at the moment taking any medications?(required)

Yes

No

If yes, list them

Please check the corresponding box if you are allergic, or had reactions to the following:

Aspirin / Advil / Tylenol

Local Anesthetic

Sedatives

Antibiotics

Certain Foods

Are you an alcohol drinker?(required)

Yes

No

For Women: Are you pregnant or have you recently missed a menstrual period?(required)

Yes

No

Are you presently breast feeding?(required)

Yes

No

Please indicate the date of your last dental exam / visit: (required)

Have you had any serious trouble associated with any previous dental treatment? (required)

Yes

No

If yes, please explain

Rate the thermal sensitivity of your teeth to hot or cold: (required)

None

Average

High

Please list any current dental needs that you are aware of

The above medical / dental health history information I have provided is true and correct.(required)

Yes