Geriatric Dental Medical History Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone Number
Address
Emergency Contact Name & Phone
Medical History
Heart Disease
High Blood Pressure
Stroke
Diabetes
Arthritis
Osteoporosis
Cancer
Kidney Disease
Lung Disease
Bleeding Disorders
Dementia/Memory Issues
Psychiatric Illness
Other
Please list other conditions or more information
List any major surgeries or hospitalizations
Medications
List all current medications (include over-the-counter & supplements)
Allergies (including medications/dental materials/latex)
Dental History
Dentures/Partials
Bleeding Gums
Dry Mouth
Tooth Pain
Difficulty Chewing/Swallowing
Jaw Problems
Oral Cancer
Other
Please provide details on any dental concerns
Consent & Signature
Patient/Responsible Party Signature
Date