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Dental Health Assessment Form Template

Create an Efficient Dental Health Assessment Form for Your Patients

Managing patient dental health can be overwhelming without the right tools. This Dental Health Assessment Form Template helps you easily collect essential information about your patients' oral health and dental history. By streamlining data collection, you can improve patient care, enhance follow-up communications, and ensure compliance with health standards, all while maintaining a user-friendly interface. Access this template and start gathering valuable insights today.

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Full name
Date of birth
Email
Phone number
Preferred contact method
Phone call
Text message
Email
No preference
What brings you in today?
Please Specify:
How would you describe your current dental discomfort, if any?
None
Mild
Moderate
Severe
Comes and goes
Which of the following make your teeth or gums sensitive?
Cold
Heat
Sweet
Biting or chewing
Brushing
None of the above
Anything else you would like us to know?
How urgent is your dental need?
Not urgent
Soon (within 2-4 weeks)
Urgent (within 48-72 hours)
Emergency (today if possible)
Do you have any of the following medical conditions?
Are you allergic to any of the following?
Please list any current medications or supplements.
Are you currently pregnant or nursing?
Yes
No
Not applicable
Prefer not to say
When was your last dental visit?
Within the last 6 months
6-12 months ago
1-2 years ago
More than 2 years ago
Never/Unsure
How often do you brush your teeth?
Never
Rarely
Sometimes
Often
Always
How often do you floss or use interdental cleaners?
Never
Rarely
Sometimes
Often
Always
How often do you use tobacco or nicotine products (smoking, vaping, smokeless)?
Never
Rarely
Sometimes
Often
Always
Do you have dental insurance?
Yes
No
Insurance provider or plan name (if applicable)
Preferred appointment times
Mornings
Afternoons
Evenings
Weekdays
Weekends
No preference
Type your full name to confirm the information provided is accurate.
Date
I consent to be contacted by phone, text, or email regarding my inquiry.
Yes
No
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Paper art illustration featuring a dental health assessment form with medical icons and clean design elements

When to use this form

Use this oral health assessment form to capture a complete snapshot of a patient's mouth before any treatment. Use it for new patient intake, school or workplace screenings, tele-dentistry triage, or pre-visit check-ins to flag urgent issues and plan care. Pair it with the Dental exam form during the visit, and, if a physician needs to sign off before surgery, add the Dental clearance form. If you need prior x-rays or chart notes, request them with the Dental records release form. With these steps, you can prioritize chair time, tailor education, and document baseline health for future comparisons.

Must Ask Dental Health Assessment Questions

  1. What dental pain, swelling, bleeding, or sensitivity are you experiencing today?

    Clear symptoms help you triage urgency and prevent complications. You can prioritize same-day relief, set expectations, and avoid surprises during treatment.

  2. When was your last dental exam and cleaning, and were any follow-ups recommended?

    This sets a baseline and reveals overdue care. Knowing pending work lets you plan the visit and schedule the right amount of chair time.

  3. Have you had cavities, gum disease, root canals, extractions, or orthodontic treatment?

    Past procedures signal risk and guide imaging, anesthesia, and recall intervals. It also informs consent and documentation for continuity of care.

  4. What medical conditions, medications, allergies, or pregnancy status could affect your dental care?

    Systemic factors change anesthesia choices, bleeding risk, and antibiotic needs. This keeps you compliant with standards and safer for the patient.

  5. How often do you brush, floss, and use fluoride, and what is your tobacco or sugar intake?

    Habits drive caries and periodontal risk, so you can tailor prevention and goals. For deeper risk profiling and counseling, pair this with the Caries risk assessment form.

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