Free Dental Clinic Medical History Form Template
Dental Clinic Medical History Form
Please fill out this form completely to help us provide the best care for your dental health.
Personal Information
Name
Date of Birth
Phone number
Medical History
Do you have any of the following conditions?
Check all that apply.
-
Heart Disease
-
Diabetes
-
High Blood Pressure
-
Asthma
-
Stroke
-
Allergies
-
Medications
Please list any current medications (including over-the-counter and supplements):
Dental History
Do you have any of the following dental conditions?
Check all that apply.
-
Tooth Sensitivity
-
Gum Disease
-
Pain or Discomfort
-
Recent Tooth Extraction
-
Orthodontics (braces)
-
Family Medical History
Has anyone in your family had any of the following conditions?
Check all that apply.
-
Gum Disease
-
Jaw Problems
-
Tooth Loss
-
Emergency Contact
Name
Phone number
Relationship
Consent and Signature
I consent to the collection of my medical history and understand the importance of providing accurate information.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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