Dental Implant Evaluation Form
Patient Name
Date of Birth
Phone
Email
Relevant Medical History
Smoking Status
No
Yes
Current Medications
Are you diabetic?
No
Yes
Relevant Dental History
Oral Hygiene
Excellent
Good
Fair
Poor
Reason for Dental Implant
Area(s) to be Evaluated
X-rays Taken?
No
Yes
Bite Assessment
Notes / Recommendations