Dental Medical History Form Template
Collects medical history that may affect dental treatment, including conditions, medications, allergies, pregnancy, and anesthesia reactions. Used by dental offices to prepare for appointments.
When to use it
- Before a new patient’s first dental visit
- When updating a returning patient’s health information
- Before a procedure involving anesthesia or numbing medicine
- When a patient reports a change in medications or medical condition
What it asks
- Full name
- Date of birth
- Phone number
- Email address
- Please list any medical conditions that may affect dental care.
- Do you have a heart condition?
- If yes or not sure, please describe your heart condition.
- Do you have a bleeding disorder or unusual bleeding?
- If yes or not sure, please describe.
- What medications or supplements do you currently take?
- Do you have any allergies or sensitivities?
- Are you pregnant or possibly pregnant?
- Have you ever had a reaction to anesthesia or numbing medicine?
- If yes or not sure, please describe the reaction.
Why it should be encrypted
These answers include private health details that patients may not want exposed. Only authorized dental staff involved in the patient’s care should be able to read them.
Tips
- Ask patients to include medication and supplement names and doses.
- Add a date so staff can tell when the history was last updated.
- Provide a way for patients to update their answers if their health changes.