This dental history form collects information about a patient's dental health, including the reason for their visit, their previous dentist, and dates of their last dental visit and x-rays. It asks the patient to check off any issues they have like sensitivity, bleeding gums, or loose teeth. It also inquires about their flossing and brushing habits as well as any medical conditions, medications, or allergies.

1. DENTAL HISTORY
NAME: ____________________________________
REASON FOR TODAY’S VISIT: ___________________
PREVIOUS DENTIST: _________________________
TODAY’S DATE: ____________________________
DATE OF LAST DENTAL VISIT: __________________
LAST DENTAL X-RAYS: _______________________
Please check any of the following issues that apply to you:
 Bad Breath
 Sensitivity to Cold
 Sensitivity to Heat
 Bite Sensitivity
 Bleeding Gums
 Mouth Sores
 Teeth Grinding
 Lost or Broken Fillings
 Loose Teeth
 Broken Teeth
 Clicking or Popping Jaw
 Food Collection between Teeth
How often do you floss? _____________________ How often do you brush? ___________________
Within the last year have you had any Hospitalizations, Illnesses, or Operations? YES NO
If YES, please describe: ______________________________________________________________________
_________________________________________________________________________________________
Have you ever had a blood transfusion? YES NO
If YES, approximate date: ________________________
WOMEN: Are you taking birth control? YES NO
Are you pregnant? YES NO  MAYBE If YES, are you nursing? YES NO
Please check any of the following issues that apply to you:
 Anemia
 Diabetes
 High Blood Pressure
 Circulatory Problems
 Heart Murmur
 Artificial Heart Values
 Mitral Value Prolapse
 Pacemaker
 Artificial Joints
 Epilepsy
 Jaw Pain
 Thyroid Issues
 Chemical Dependency
 Tobacco Habit
 Back Problems
 Hemophilia
 Blood Disease
 Headaches
 Ulcers
 Cancer
 HIV
 Hepatitis
 Chemotherapy
 Latex Allergy
 Asthma
 Respiratory Disease
List all the medications you are taking:
__________________________________________________________________________________________
__________________________________________________________________________________________
List all of your allergies:
__________________________________________________________________________________________
__________________________________________________________________________________________