Dental Anxiety Patient Medical History Form
Personal Information
Full Name
Date of Birth
Email
Phone Number
Address
Dental Anxiety
Do you feel anxious about visiting the dentist?
Yes
No
If yes, what causes your anxiety?
Have you had any negative dental experiences?
Yes
No
If yes, please describe:
Would you like to discuss your anxiety with the dentist?
Yes
No
Medical History
Are you currently under medical care?
Yes
No
If yes, please explain:
List any medications you are currently taking:
Do you have any allergies?
Yes
No
If yes, please list:
Do you have any of the following conditions?
Heart Disease
Diabetes
Asthma
Epilepsy
Other
If other, please specify:
Additional Information
Is there anything else you would like us to know?