The information on this form can be collected over time as the team builds a relationship with the patient. This form also helps the practice document the patient’s dental health history with the practice, in terms of the patient’s willingness to accept treatment, anxiety toward dentistry and appointment history.

This form should be reviewed by all staff who will be interacting with the patient prior to the patient’s appointment. Any concerns regarding the patient’s dental health (i.e., anxiety or resistance) should be communicated to the dental team in the morning meeting prior to the patient’s appointment. For practices that use an electronic record system, the information can be entered in an area that can be viewed by all staff, but not seen by patients.

Note: In order for this form to not be considered part of a patient’s record, which would need to be released upon request, the practice should establish a policy regarding the internal utilization and intent of the form. Additionally, the form should be utilized in a professional manner and be limited to use for business purposes. The information on the form is protected by law.