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Dental Screening Form Template

Ensure Smooth Assessments with Our Dental Examination Form

Struggling to evaluate your patients' oral health efficiently? Our Dental Screening Form Template is designed for dental professionals like you, ensuring quick and comprehensive assessments. This user-friendly template simplifies gathering vital dental history, streamlines patient evaluations, and supports effective treatment planning while maintaining WCAG-aligned accessibility standards. Explore how this tool can enhance your practice and provide better care to your patients.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Phone number
Email address
Street address (include city, state, ZIP)
Preferred appointment date
Preferred time of day for appointment
Morning
Afternoon
Evening
Any time
Preferred contact method
Phone call
Text message
Email
Any
How did you hear about us?
Friend or family
Online search
Social media
Advertisement
Community event
Healthcare referral
Prefer not to say
Other
Please Specify:
Are you currently under the care of a physician?
Yes
No
Please indicate any medical conditions you have been diagnosed with
Please list any other medical conditions
Do you have any allergies?
No known allergies
Medications (e.g., penicillin)
Latex
Local anesthetics
Metals
Food
Other (please specify below)
Prefer not to say
Please list allergies and reactions
Current medications and supplements (name and dose, if known)
Do you use tobacco or vape?
Never
Former
Current
Are you pregnant or think you may be pregnant?
Yes
No
Not applicable
Prefer not to say
Have you ever been advised to take antibiotics before dental treatment?
Yes
No
Not sure
What brings you in for a free screening today?
Please Specify:
Please describe any specific concerns or goals
Current dental discomfort level
None
Mild
Moderate
Severe
Do your gums bleed when you brush or floss?
Yes
No
Sometimes
Not sure
Do your teeth feel sensitive to any of the following?
Cold
Heat
Sweets
Biting or chewing
None
Do you grind or clench your teeth?
Yes
No
Not sure
When was your last dental visit?
Do you have a regular dentist?
Yes
No
Are you interested in information about cosmetic dentistry options?
Yes
No
Maybe
Emergency contact full name
Emergency contact phone
Insurance provider
Member ID or policy number
Primary policyholder name
Do you have dental insurance?
Yes
No
I consent to receive a limited dental screening and understand it is not a comprehensive exam.
Yes
No
I authorize the clinic to contact me regarding appointments and follow-up.
Yes
No
Print your full name as an electronic signature
Date
I acknowledge that I have reviewed the privacy notice.
Yes
No
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Colorful paper art illustration depicting a dental screening form designed for FormCreatorAI

When to use this form

Use this form when you need a fast, consistent check of oral health before a full exam. It helps hygienists, school nurses, and mobile clinics document findings, flag urgent issues, and guide next steps. Bring it to back-to-school events to spot cavities and send clear referrals. In community outreach, you can triage pain, note visible decay, and schedule follow-up care. Pair it with a Caries risk assessment form to gauge decay risk and a Dental health assessment form to capture broader history. The result: clean, comparable data you can share with caregivers or providers and a simple plan for prevention or treatment.

Must Ask Dental Screening Questions

  1. What is your main concern or reason for today's visit?

    These details set priorities and help you focus the screening. Clear goals improve triage and make your recommendations more relevant.

  2. Have you had dental pain, swelling, or bleeding gums in the past 6 months?

    Symptoms flag active disease and urgency. They guide whether you need radiographs, urgent referral, or preventive coaching today.

  3. When was your last professional cleaning and exam, and were any issues found?

    Timing and findings show risk and recall needs. They also reveal unfinished treatment that you can schedule or escalate.

  4. Do you have any medical conditions, medications, or allergies, especially to latex, anesthetics, or antibiotics?

    This protects patient safety and informs what you can do on-site. If needed, use a Dental clearance form to coordinate with the physician.

  5. Do you consent to share your screening results with caregivers, schools, or your physician, and who should receive them?

    Consent makes communication clear and compliant. For privacy details, point patients to the Dental HIPAA form.

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