Prosthodontic Dental Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Contact Number
Email
Address
Medical History
Physician's Name
Physician's Contact
Current Medical Conditions
Medications
Allergies
History of Hospitalization/Surgeries
Smoking
No
Yes
Alcohol Consumption
No
Yes
Dental History
Chief Dental Complaint
Past Dental Treatments
Oral Habits (e.g. bruxism, clenching, nail-biting)
Oral Hygiene Routine
History of Denture Use
Additional Information
Expectations from Prosthodontic Treatment
Other Relevant Information