Family Dental History Questionnaire
Patient Information
Full Name
Date of Birth
Contact Number
Address
Immediate Family Members
Please provide dental health information for your immediate family members.
Relation
Age
Dental Issues (if any)
Father
Mother
Sibling 1
Sibling 2
Family Dental History
Any family members with frequent cavities?
Yes
No
Family history of gum disease?
Yes
No
Family history of orthodontic treatments (e.g. braces)?
Yes
No
Any history of oral cancer in family?
Yes
No
Other relevant family oral health conditions