New Patient Dental History Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Dentist Information
Previous Dentist
Date of Last Dental Visit
Dental History
Are you experiencing any dental problems?
Tooth pain
Bleeding gums
Sensitivity
Swelling
Other
If other, please specify
Have you had any of the following?
Braces
Gum treatment
Extractions
Root canal
Denture/Partial
Medical History
Physician's Name
Please list any medical conditions
Please list any medications
Any drug allergies?
Additional Information
Do you have any specific dental concerns or goals?