Pre-Operative Dental History Form
Patient Name
Date of Birth
Age
Gender
Female
Male
Other
Contact Number
Referring Dentist / Doctor
Chief Complaint
Dental History
Medical History
Allergies
Current Medications
Previous Surgeries / Hospitalizations
Family History of Dental / Medical Problems
Clinical Examination / Findings
Provisional Diagnosis
Planned Surgery / Treatment
Dentist Name / Signature
Date