Dental History Form
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Dental History Form
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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.
What's included
- Prior dental treatment history with dates and details
- Periodontal health assessment and treatment history
- TMJ/TMD symptom screening and bruxism documentation
- Dental anxiety scale for sedation planning
- Medically relevant conditions impacting dental care
- Oral hygiene habits and home care documentation
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- General dentistry new patient intake documentation
- Periodontal practice comprehensive assessment
- Oral surgery pre-operative history collection
- Orthodontic treatment planning and records transfer
All form fields
12 fields across 2 pages. Customize any field after signing up.
How to use the Dental History Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Dental History Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Dental History Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 12 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Dental History Form HIPAA compliant?
Yes. All Formisoft templates, including the Dental History Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 12 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Dental History Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Dental History Form for your practice. Set up in minutes.
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