New Patient Form
Patient ID:
Your answer
Location (where services were performed):
Your answer
Grant Year *
Gender:
Race:
Age:
Your answer
Currently Employed:
Household Income:
Frequency of Dental Visits:
Last Dental Visit:
Emergency Dental Care:
Do your gums bleed when you brush or floss?
Are your teeth sensitive to hot, cold, sweets, or pressure?
Are you currently in dental pain or discomfort?
Do you have any sores or ulcers in your mouth?
Is your mouth often dry?
Do you have bad breath?
Do you have dental insurance?
Dentures/Partials:
Do you wear dentures to eat?
Posterior Occlusal Contact:
Substantial Oral Debris:
Severe Gingival Inflammation:
Number of Upper Teeth Present:
Number of Lower Teeth Present:
Untreated Decay:
Root Fragments:
Tooth Mobility:
Need for Periodontal Care:
Severe Dry Mouth:
Suspicious Soft Lesion:
Filled Teeth:
Missing Teeth:
Treatment Urgency:
Treatment Rendered:
Referral Given:
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