Dental Medical History Form Checklist

Audit Verification
Patient/Guardian Name
Dentist Signature
General details
Patient's Name
Date of Birth
Age
Sex
Contact phone numbers
Issue
Do you have any Dental pain?
Last examination date if any
Was the previous dental care satisfying?
Are you scared of dental treatment?
Any other concern area.
Overall Checks
Do you have any allergies?
Mention the name of the medicine/ treatment if any
Do you have any previous record/issues/reactions to local anesthetic, metals, or sedation
Mention any previous illnesses/surgeries/hospitalizations
Mention the name of recreational drugs if any
Please select the medical history(at present or previously followed)if any

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