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Dental Exam Form Template

Streamline Your Dental Practice with a Comprehensive Exam Form

Gathering accurate patient information can be a challenge for dental practices, but it doesn't have to be. This dental exam form template is designed for dentists and hygienists who want to efficiently collect essential data from patients during their visits. With this template, you can easily capture critical details like medical history, current medications, and oral health concerns-all in a streamlined manner that enhances the patient experience. Enjoy benefits like time savings, improved data accuracy, and effortless compliance with WCAG-aligned standards. Explore the live template to simplify your exam process today.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Email address
Mobile phone number
Preferred contact method
Phone call
Text message
Email
No preference
Preferred date for your free exam
Primary reason for your visit today
Do you have any of the following conditions? (Select all that apply)
Please Specify:
Do you have any allergies? (Select all that apply)
No known allergies
Penicillin or antibiotics
Latex
Local anesthetics
Metals or jewelry
Nuts or foods
Prefer not to say
Other
Please Specify:
Please list current medications or supplements
Do you use tobacco or vape products?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Not sure
Date of last dental visit
Do you experience tooth sensitivity? (Select all that apply)
No sensitivity
Cold
Hot
Sweet
Pressure or chewing
Occasional
Frequent
Current dental discomfort level
No pain
Mild
Moderate
Severe
Do you have dental insurance?
Yes
No
Emergency contact full name
Emergency contact phone
I consent to a dental examination and necessary diagnostic x-rays for the free exam.
Yes
No
Name of person giving consent (type full name as signature)
Date of consent
I confirm the information provided is accurate to the best of my knowledge.
Yes
No
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring a dental exam form with sections for patient information and dental assessments

When to use this form

Use this template at new patient visits, routine checkups, pre-op clearances, and school or mobile clinics. It helps you capture history, chart findings, radiograph notes, and treatment plans in one place, so your team can move from assessment to next steps without delays. Hygienists, dentists, and office managers benefit from consistent data that supports recalls, referrals, and insurance claims. For community programs, pair it with the Dental screening form to separate brief screenings from full chairside exams. To target prevention and recall intervals, add the Caries risk assessment form. For privacy and record sharing, collect permissions alongside a Dental HIPAA form.

Must Ask Dental Exam Questions

  1. What brings you in today, and what symptoms concern you most?

    This clarifies the primary issue, so you can focus the exam and any imaging. It also sets expectations and helps you triage if multiple problems exist.

  2. When was your last dental visit, and what treatment did you receive?

    Recent care affects todays findings and the timing of follow-ups. It prevents duplicate work and flags unfinished treatment.

  3. Do you have tooth pain, hot/cold sensitivity, or bleeding gums?

    These red flags guide percussion, palpation, and periodontal checks. Your answers speed diagnosis of decay, fractures, or gum disease.

  4. What medical conditions, medications, and allergies should we know about?

    Systemic health and drugs can change bleeding risk, healing, and anesthesia choices. Disclosing them keeps you safe and informs the plan.

  5. Do you authorize us to share your dental records with referred specialists or insurers?

    Consent lets your team coordinate care and process claims faster. If needed, complete an accompanying Authorization to release dental information form.

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