Dental Patient Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone
Email
Address
Dental History
Main Dental Concerns
Last Dental Visit
Any Previous Dental Treatments?
Oral Habits (e.g. Grinding, Clenching)
Medical History
Do you have any medical conditions?
Allergies (including medications)
Current Medications
Do you smoke?
Yes
No
Are you pregnant? (if applicable)
Yes
No
Not Applicable
Additional Notes