Dental Patient Health Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone
Email
Address
Medical History
Are you currently under a physician's care?
Yes
No
If yes, please describe
Do you have, or have you had, any of the following? (Check all that apply)
Heart Disease
Diabetes
High Blood Pressure
HIV/AIDS
Asthma
Bleeding Disorders
Cancer
Kidney Problems
Liver Problems
Other
If 'Other', please specify
Are you currently taking any medications?
Yes
No
If yes, please list all medications
Do you have any allergies?
Yes
No
If yes, please list all allergies
Dental History
Date of last dental visit
Have you ever had any of the following? (Check all that apply)
Gum Disease
Tooth Pain
Jaw Pain
Mouth Sores
Bleeding Gums
Sensitive Teeth
Grinding/Clenching
Other
If 'Other', please specify
Do you have any concerns about your dental health?
Consent & Signature
Name
Date