Dental medical history form

A dental, medical history form is a document that the patient fills out. The dentist next uses this information to assess if any pre-existing conditions could interfere with basic dental operations. The patient must fill out this information because patients will most likely be sedated and in a semi-conscious state during a visit to the dentist. All information pertinent to the individual's current situation should be recorded.

Eligibility

To be eligible to fill out a dental medical history form, you must be a patient of the dental office.

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Questions for Dental medical history form

1.

Patient Information

2.

Name

The answer should be a text input.
3.

Height

The answer should be a text input.
4.

Weight

The answer should be a number input.
5.

DOB

The answer should be a date input.
6.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Other
  4. Prefer not to say
7.

Emergency Contact Number

The answer should be a phone number.
8.

Dental History

9.

Do your gums bleed when you brush?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
10.

Have you ever had orthodontic (braces) treatment?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
11.

Are your teeth sensitive to cold, hot, sweets or pressure?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
12.

Do you have earaches or neck pains?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
13.

Have you had any periodontal (gum) treatments?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
14.

Do you wear removable dental appliances?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
15.

Have you had a serious/difficult problem associated with any previous dental treatment?

if yes, explain

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
16.

How would you describe your current dental problem?

The answer should be a text input.
17.

Date of your last dental exam 

The answer should be a date input.
18.

Date of last dental x-rays 

The answer should be a text input.
19.

Medical History

20.

Are you in good health? 

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
21.

Has there been any change in your general health within the past year?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
22.

Are you now under the care of a physician?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
23.

Do you use drugs or other substances forrecreational purposes?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know
24.

Has a physician or previous dentist recommendedthat you take antibiotics prior to your dental treatment?

The answer should be a single choice:
  1. Yes
  2. No
  3. Don't know

Similar Ideas

  • Medical and Dental History Form
  • Dental Health History Form
  • Patient Information and Dental History Form
  • Dental Patient History Form

Here are some FAQs and additional information
on
Dental medical history form

What kind of information is asked in the dental medical history form?

Identification data like name, date of birth, phone numbers, and emergency contact information. No financial information should be kept in the dental record. It should include systemic diseases, allergies, reactions to anesthetics, current medications and treatment, herbal supplements, surgeries, injuries, and diet.

Why do dentists ask about medical history?

A patient's medical history is a vital part of his or her dental history and increases the dentist's awareness of diseases and medication which might interfere with the patient's dental treatment. Your allergies to medications or a birth condition are very vital information a dentist needs to know before any procedure.

Where should a medical-dental history be stored?

Patient records should be kept safely, confidentially, and securely at all times. The dental records should be stored securely in a fireproof cupboard or filing cabinet. The area where the dental records are kept should be protected from unauthorized access, theft and damage.

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