Family Dental Health History Checklist
Family Member Information
Name
Relation
Age
Dental Provider
Family History of Dental Conditions
Condition
Mother
Father
Sibling
Grandparent
Tooth Decay (Cavities)
Gum Disease (Periodontitis)
Tooth Loss
Malocclusion (Misaligned Teeth)
Oral Cancer
Other
Additional Notes
I confirm that the above information is true to the best of my knowledge.
Signature:
Date: