Dental History Form

The Dental History Form provides a thorough documentation of a patient's oral health background for general dentistry, periodontal, orthodontic, and oral surgery practices. It captures prior dental treatments including restorations, crowns, bridges, implants, root canals, extractions, and dentures. Each entry includes approximate date, treating dentist, and any complications experienced. The form also documents the patient's current oral hygiene regimen, including brushing frequency, flossing habits, mouthwash use, and electric versus manual toothbrush preference.

Periodontal health is assessed through questions about gum bleeding, recession, mobility, bone loss diagnosis, and prior scaling and root planing or periodontal surgery. The form includes TMJ/TMD screening with questions about jaw clicking, locking, pain on opening, bruxism, and nightguard use. Orthodontic history covers prior braces, retainer use, and any relapse concerns. Dental anxiety is assessed using a validated scale to help providers plan appropriate sedation or behavioral management approaches.

The template also captures medically relevant information that impacts dental care: bisphosphonate use (risk of osteonecrosis), anticoagulant therapy (bleeding risk), prosthetic joint replacements (antibiotic prophylaxis considerations), history of infective endocarditis, radiation therapy to the head and neck, and immunosuppressive medications. This cross-medical documentation ensures safe dental treatment planning and appropriate medical consultation when needed.