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.
3 minutes to complete
Eligibility
To be eligible to fill out a dental medical history form, you must be a patient of the dental office.
Questions for Dental medical history form
Questions
Patient Information
Name
Height
Weight
DOB
Gender
- Male
- Female
- Other
- Prefer not to say
Emergency Contact Number
Dental History
Do your gums bleed when you brush?
- Yes
- No
- Don't know
Have you ever had orthodontic (braces) treatment?
- Yes
- No
- Don't know
Are your teeth sensitive to cold, hot, sweets or pressure?
- Yes
- No
- Don't know
Do you have earaches or neck pains?
- Yes
- No
- Don't know
Have you had any periodontal (gum) treatments?
- Yes
- No
- Don't know
Do you wear removable dental appliances?
- Yes
- No
- Don't know
Have you had a serious/difficult problem associated with any previous dental treatment?
if yes, explain
- Yes
- No
- Don't know
How would you describe your current dental problem?
Date of your last dental exam
Date of last dental x-rays
Medical History
Are you in good health?
- Yes
- No
- Don't know
Has there been any change in your general health within the past year?
- Yes
- No
- Don't know
Are you now under the care of a physician?
- Yes
- No
- Don't know
Do you use drugs or other substances forrecreational purposes?
- Yes
- No
- Don't know
Has a physician or previous dentist recommendedthat you take antibiotics prior to your dental treatment?
- Yes
- No
- Don't know
Forms Similar to Dental medical history form
- 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.
Want to use this template?
Loved by people at home
and at work
