Geriatric Dental History Form
Patient Information
Full Name
Date of Birth
Contact Number
Address
Medical History
Primary Physician
List any current medical conditions
Are you currently taking any medications?
Yes
No
If yes, please list them
Dental History
When was your last dental visit?
Have you experienced any of the following? (Check all that apply)
Tooth Pain
Bleeding Gums
Dry Mouth
Difficulty Chewing
Dentures/Partials
Other dental issues or symptoms
Habits & Lifestyle
Do you smoke or use tobacco?
Yes
No
Describe your daily oral hygiene routine
Additional Notes
Anything else you would like to share?