Special Needs Dental History Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Contact Number
Email
Address
Medical History
Diagnosis/Disability
Primary Physician
Current Medications
Allergies
Other Medical Conditions
Dental History
Previous Dentist
Date of Last Dental Visit
Current Dental Concerns
Oral Habits (e.g., thumb sucking, teeth grinding)
Special Care Considerations
Behavioral Concerns
Mobility/Accessibility Needs
Preferred Communication Method
Other Special Needs or Important Information