Pregnancy Dental Medical History Form
Personal Information
Name
Date of Birth
Address
Phone
Email
Prenatal Information
Obstetrician's Name
Obstetrician's Phone
Pregnancy Weeks
Estimated Due Date
Complications (if any)
Dental History
Current Dental Concerns
Last Dental Visit
How often do you brush?
Do your gums bleed when brushing or flossing?
Yes
No
Medical History
List any medications you are currently taking
Allergies
Medical Conditions
Additional Notes
Other Information