Use This Template

Dental Health History Form

Gather details about your patient’s current and prior dental history using our free Dental Health History Form. Our thorough template has you covered! You can rest assured knowing that you are accurately collecting as much information as possible regarding your patient’s dental conditions when using our template. All aspects of the template can be easily customized to match your needs.

We also included a simple internal section for your staff to indicate once they’ve added a patient’s medical history to their file. Using workflow statuses and the Entries page, staff members can easily monitor each entry’s progress and status.

All data collected can be made HIPAA compliant with our Enterprise plan after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure both at rest and in transit.

Go ahead and customize this template by adding, removing, and editing fields as you see fit. You can modify the existing questions or add your own in as necessary. Additionally, you can style this form as you please or keep your org’s branding consistent with other forms using our Organization Theme feature. You can also directly embed this form onto your practice’s website or portal for easier access, if you’d like.

Dental Health History Form

Use our dental health history form to gather a patient's current and prior dental health history.



  • Public
  • Internal


  • Incomplete
  • Submitted
  • Processed