Special Needs Dental Medical History Form
Patient Information
Patient Name
Date of Birth
Address
Phone
Email
Emergency Contact
Emergency Contact Name
Relationship
Phone
Medical Details
Primary Physician
Physician Phone
Diagnosis / Special Needs
Current Medications (please list)
Allergies (medications, food, latex, etc.)
Hospitalizations/Surgeries (with dates)
Medical History
Heart Problems
Lung Problems
Kidney Problems
Liver Problems
Seizure Disorder
Diabetes
Bleeding Disorders
Asthma
Autism Spectrum
Down Syndrome
None of the above
Other medical conditions or relevant details
Dental Information
Last Dental Visit
Previous dental experiences and any difficulties
Assistance needed for dental treatment (ex: wheelchair, communication)
Consent
Name of Guardian/Responsible Party
Date