Free Dental History Form Template

Gathering patient history can be challenging, especially when it comes to capturing essential dental information. This dental history form template helps dental offices like yours collect important health details and past treatment histories, ensuring you provide tailored care for your patients. Benefit from easy and quick patient onboarding, accurate data collection, and improved communication with your team and patients, all while ensuring compliance with health and safety standards. Explore how simple it is to enhance your practice with our live template.

When to use this form

Use this template at new patient intake, at recall visits to update health changes, before sedation or surgery, and for emergency visits. It helps you find risks like heart conditions, diabetes, allergies, and blood thinners so you can plan safe care and get informed consent. Pair it with the Dental exam form at first visits to align findings with history. Ask returning patients to review and sign an update when meds or diagnoses change. For privacy and consent to share PHI, provide your Dental HIPAA form alongside this form. Collecting complete, current answers reduces cancellations, avoids adverse reactions, and gives your team a clear treatment path.

Must Ask Dental History Questions

Which medical conditions have you been diagnosed with (e.g., heart disease, diabetes, asthma, bleeding disorders)?
This flags risks that change anesthesia, antibiotics, and healing plans. Clear options and examples prompt accurate, complete responses.
Which medications and supplements do you take, including blood thinners, and what are the doses?
Medication lists prevent interactions and help you plan timing around procedures. If a response includes anticoagulants or recent chemo, you may request physician input with the Dental clearance form.
Do you have any allergies or adverse reactions to medicines, latex, metals, or local anesthetics?
Allergy data prevents emergencies and helps you select safe materials. Asking for the reaction type (rash, anaphylaxis, nausea) improves triage and documentation.
What major dental treatments have you had, and did you have any problems with anesthesia or bleeding?
History of extractions, implants, or root canals shapes your exam and treatment plan. If you need prior x-rays or notes, you can authorize a transfer with the Dental records release form.
Do you smoke, vape, drink alcohol, or use recreational drugs, and how often?
These factors affect anesthesia, healing, and implant success, so you can set realistic timelines and aftercare. Frequency data turns vague answers into actionable risk levels.

More Forms

Question		Response
Full legal name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Email address		[email protected]
Mobile phone		555 555 5555
Home address (street, city, state, ZIP)		This is a test
Gender		Man
If you selected prefer to self-describe, please specify		This is a test
Preferred contact method		Any
Are you currently under a physician's care?		Yes
Physician name and clinic		This is a test
Do you have or have you had any of the following conditions?		Asthma
Are you currently being treated for any medical condition?		No
Please describe any current treatments or conditions		This is a test
Surgeries or hospitalizations in the past 5 years?		No
Please list surgeries or hospitalizations (with dates if known)		This is a test
Pregnancy or breastfeeding status		Breastfeeding
Do you require antibiotic premedication for dental treatment?		Yes
Have you had any adverse reaction to dental anesthetic or epinephrine?		No
Tobacco or nicotine use		Vape/e-cigarettes
Alcohol use frequency		Rarely
Do you use recreational drugs?		Yes
Do you take any prescription or over-the-counter medications, vitamins, or supplements?		No
List all current medications and dosages (or attach a list)		This is a test
If you have allergies, please describe the reactions		This is a test
Are you allergic to or have you had reactions to any of the following?		Acrylic or dental materials
What is the main reason for your visit today?		This is a test
Date of last dental visit		2025-10-15T00:00:00.000Z
Have you had a dental cleaning in the past 12 months?		Yes
How often do you brush your teeth?		More than twice daily
How often do you floss?		Never
Do you use fluoride products?		Mouth rinse only
Do your gums bleed when brushing or flossing?		No
Select any current dental concerns		Dry mouth
Are you experiencing dental pain today?		No
If experiencing pain, how would you rate it?		Moderate
Do you clench or grind your teeth?		Yes
How satisfied are you with the appearance of your teeth?		Very dissatisfied
Which treatments are you interested in learning more about?		Not sure
Do you have dental insurance?		No
Insurance carrier		This is a test
Subscriber name		This is a test
Subscriber ID or policy number		This is a test
Subscriber date of birth		2025-10-15T00:00:00.000Z
Relationship to subscriber		Spouse
Emergency contact full name		John Smith
Emergency contact phone		555 555 5555
Emergency contact relationship		Child
I confirm that the information provided is accurate and complete to the best of my knowledge.		Disagree
I consent to dental examination, necessary diagnostics (including x-rays), and discussion of treatment options.		Disagree
I authorize the release of necessary dental information to my insurer for the purpose of claims processing.		Strongly disagree
Electronic signature (type your full legal name)		This is a test
Signature date		2025-10-15T00:00:00.000Z
I consent to receive appointment reminders and important updates by		Do not send reminders

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Dental History Form Template

Streamline Patient Intake With a Dental History Form

When to use this form

Must Ask Dental History Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Dental History Form Template

Streamline Patient Intake With a Dental History Form

When to use this form

Must Ask Dental History Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results