Dental Clinic Medical History Form
Dental Clinic Medical History Form
Please complete this form to help us understand your dental and medical history for safe and effective treatment.
Name
Date of Birth
Phone number
Emergency Contact Name
Emergency Contact Phone number
Medical History
Current Medications
Allergies (medications, food, etc.)
Previous Medical Conditions
e.g., diabetes, heart disease
Dental History
Previous Dental Treatments
Current Dental Issues (e.g., pain, sensitivity)
Frequency of Dental Visits
Lifestyle Information
Tobacco Use
-
I do not use tobacco.
-
I currently use tobacco (cigarettes, cigars, or chewing tobacco).
-
I used to use tobacco but have quit.
-
I occasionally use tobacco.
Alcohol Consumption
-
I do not consume alcohol.
-
I consume alcohol occasionally (1-2 times a month).
-
I consume alcohol regularly (1-2 times a week).
-
I consume alcohol daily.
Diet and Oral Hygiene Practices
Consent and Signature
I acknowledge that the information provided is accurate and complete to the best of my knowledge. I consent to the use of this information for my dental care.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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