Dental Patient Medical History Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone
Email
Address
Medical History
Primary Physician
Physician Phone
Current health status
Current medications (list below)
Allergies (drug, food, etc.)
Hospitalizations or surgeries
Please check if you have had or have any of the following:
Diabetes
High Blood Pressure
Heart Disease
Asthma
Bleeding Disorders
Arthritis
Cancer
Epilepsy / Seizures
Hepatitis
HIV/AIDS
Kidney Disease
Tuberculosis (TB)
Thyroid Problems
Blood Transfusion
Other
If other, please specify
Dental History
Main dental concern / Chief complaint
Date of last dental visit
Previous dental treatments
Oral hygiene habits