Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Dental History Form
Your information
Full Name *
Last Dental Visit Date
____ / ____ / ________
Prior Dental Treatments
Periodontal Health History
TMJ/TMD Symptoms
Orthodontic History
Additional details
Oral Hygiene Routine
Dental Anxiety Level
- Not anxious
- A little anxious
- Moderately anxious
- Very anxious
Bruxism/Nightguard Use
Relevant Medical Conditions
Current Medications
| Medication | Dose | How often |
|---|---|---|
Patient Signature
Date
Dental History Form template from formisoft.com. formisoft.com/intake-templates/dental-history