Dental history form template

About this dental history form

Dental treatment can be affected by heart conditions, blood thinners, diabetes, pregnancy and allergies to anaesthetics or latex, so dental clinics ask for both dental and medical history. This form covers the reason for the visit, past treatments, current problems such as sensitivity or bleeding gums, habits like grinding, and the medical alerts dentists need.

Use it with the patient information form for new-patient registration.

What’s on the dental history form

The template has 5 sections and 17 questions. Every one can be renamed, moved or deleted.

• Patient: Full name; Date of birth; Phone; Date
• Your visit: Reason for visit (choose one: Check-up, Pain, Cleaning, Cosmetic, Emergency, Other); Describe any pain or problem; Last dental visit; How do you feel about dental visits? (choose one: Relaxed, A little nervous, Very anxious)
• Dental history: Problems (tick all that apply: Sensitive teeth, Bleeding gums, Bad breath, Grinding or clenching, Jaw pain, Loose teeth, Dry mouth); Past treatment (tick all that apply: Fillings, Root canal, Extractions, Crowns or bridges, Braces, Implants, Dentures); Brushing per day (choose one: Once, Twice, More); Flossing (choose one: Never, Sometimes, Daily)
• Medical alerts: Alerts (tick all that apply: Heart condition, High blood pressure, Diabetes, Bleeding disorder, Blood thinners, Pregnant, Smoker); Allergies (anaesthetic, latex, penicillin…); Current medications
• Consent: Agreement: “I consent to examination and the dental treatment explained to me.”; Signature with date

Tips

• Ask patients to bring a list of medicines.
• Review medical alerts at every visit, not just the first.
• Note anxiety; a calmer approach helps nervous patients.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.