Dental Medical History Form

About this form

The dental medical history form is a medical history document used by dental practices. Comprehensive dental-specific medical history covering systemic conditions, medications, and allergies. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 14 fields:

• Patient Name — Text
• Date of Birth — Date
• Heart Disease / Heart Murmur — Multiple choice
• Diabetes (Type 1 or Type 2) — Multiple choice
• High Blood Pressure (Hypertension) — Multiple choice
• Bleeding Disorders — Multiple choice
• Osteoporosis — Multiple choice
• Bisphosphonate Use (Fosamax, Boniva, etc.) — Multiple choice
• Current Medications and Dosages — Long answer
• Known Allergies (medications, latex, metals) — Long answer
• Previous Hospitalizations or Surgeries — Long answer
• Primary Care Physician Name and Phone — Text
• Patient Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the pre-treatment review, so the provider can read the patient's history before the visit. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.