Oral-Systemic Health Assessment | Luxury Tooth Booth Inc.

1. Patient and Form Information

Patient Full Legal Name *

Date of Birth *

Today's Date *

Person Completing This Form *

Name and relationship of person completing form, if not the patient

2. Care Team

Primary Care Provider Name and Practice

Primary Care Provider Phone

Primary Dentist Name and Practice

Primary Dentist Phone

Relevant medical specialists, diagnoses, or contact information

3. Medications, Supplements, and Allergies

List all prescription medications, over-the-counter medications, vitamins, herbs, supplements, inhalers, injections, and as-needed medications. Include dose and frequency if known. *

Any medication started, stopped, or changed within the last 90 days?

Known allergies or sensitivities

Medication changes, allergies, reactions, latex sensitivity, dental-material sensitivity, food allergies, or chemical/fragrance sensitivities

4. Current Symptoms and Care Considerations

Select any symptoms experienced in the last 30 days.

Describe symptoms or health changes that may affect comfort, mobility, positioning, communication, eating, oral hygiene, healing, or ability to receive care.

5. Medical Conditions

Select all conditions that apply, currently or in the past. If unsure, select “Not sure” and add details in the comments field.

Cardiovascular and Blood Health

High blood pressure

Heart disease, heart failure, or coronary artery disease

Heart rhythm disorder / arrhythmia

Heart valve condition, prosthetic valve, or valve repair

History of infective endocarditis

Stroke or transient ischemic attack

Bleeding or clotting disorder; anemia; or blood-thinning medication

Metabolic, Endocrine, and Bone Health

Diabetes, prediabetes, or elevated blood sugar

Thyroid disorder

Osteoporosis or osteopenia

Bisphosphonate, denosumab, or other bone-strengthening medication

Immune, Respiratory, Neurological, and Other Health

Please list diagnoses, treatment details, providers, medications, or instructions that may affect oral health, healing, bleeding risk, infection risk, comfort, or appointment planning.

6. Airway and Sleep Screening

This section is for screening and education only; it does not diagnose sleep apnea or another sleep disorder.

Frequent snoring

Witnessed pauses in breathing, gasping, choking, or snorting during sleep

Mouth breathing during the day or sleep

Waking unrefreshed, daytime fatigue, or sleepiness

Morning headaches

Frequent nighttime waking or difficulty returning to sleep

Clenching or grinding teeth

None of the above

Has the patient had a sleep study?

Current sleep treatment, if applicable

Sleep-study, CPAP/BiPAP use or tolerance, oral-appliance, or sleep-health notes

7. Antibiotic, Steroid, and Recent Health History

Antibiotic use within the last 12 months

Steroid use within the last 12 months

Has a provider instructed the patient to take antibiotics before dental procedures?

Significant infection, hospitalization, surgery, chemotherapy, radiation, or major health event in last 12 months?

Please provide details, medication names, dates, provider instructions, or other relevant information.

If premedication is “Yes” or “Not sure,” complete the separate Premedication, Medical Clearance, and Treating-Provider Contact Form if requested by Luxury Tooth Booth Inc.

8. Nutrition, Hydration, and Daily Habits

Usual hydration level

Approximate daily water intake

Added sugar or sweetened/acidic beverage intake

Alcohol use

Tobacco, nicotine, vaping, or cannabis smoking/vaping

Dietary pattern or restrictions

Please share any nutrition, hydration, appetite, nausea, reflux, swallowing, weight-management medication/procedure, or lifestyle considerations that may affect oral health or care planning.

9. Dental Materials, Environmental Exposures, and Preferences

Silver-colored amalgam fillings

Previous replacement or removal of amalgam fillings

Dental-material or metal sensitivity/concern

Mold exposure concern at home or work

Occupational chemical, fragrance, or air-quality concern

None known

Not sure

Please describe any relevant history, sensitivities, concerns, or preferences, including biological, ingredient-conscious, fragrance-free, or fluoride preferences.

10. Health Goals and Additional Notes

Improve oral comfort

Reduce dry-mouth concerns

Improve gum health or reduce cavity risk

Maintain natural teeth and daily oral hygiene

Learn about airway health, snoring, mouth breathing, or sleep apnea

Support overall wellness and understand oral-systemic connections

Coordinate care with medical, dental, specialist, caregiver, or facility teams

What would make dental hygiene care safer, easier, more comfortable, or more supportive? Please include additional notes, concerns, or questions.

11. Attestation and Electronic Signature

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that I should notify Luxury Tooth Booth Inc. of changes in the patient's diagnoses, medications, allergies, providers, treatment status, health conditions, or care needs.

Name of Person Signing *

Relationship or Role *

Date Signed *

Electronic Signature *

By typing your full legal name, you intend to sign this form electronically.