Dental History

Bring a patient's dental background, medical history, and lifestyle habits together in a single reference form.

Use this template

Patient Name

First Name

Last Name

Previous Dentist Name

First Name

Last Name

Last Visit

Last Cleaning

Do you have any other disease/condition not listed above?

Do you use recreational drugs?

Yes No

How often do you consume alcoholic beverages?

Never Occasionally Weekly Daily

Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration

Are you currently pregnant or trying to become pregnant?

Yes No

Are you currently use a prescription type contraceptive? Please explain

Signature

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