Dental Health History Questionnaire

Let's get ready for your next dental appointment.What's your first name?And your last name?What's your date of birth, {{field:01F76TE6ZRFV7294C4TYGRBX4Y}}?Please select any of these issues you've experiences in the past.

Bleeding gums, Unpleasant taste, Bad breath, Grinding teeth, Sensitive teeth, Loose teeth, Swelling in mouth

What's the reason for your next visit?

Just a check up, Pain or other issues

Can you describe what problems you're having now?Thanks {{field:01F76TE6ZRFV7294C4TYGRBX4Y}}. We'll see you soon.

Collect up to 3.5x more data with Typeform

Find out if they really floss, once and for all.

Is everyone completely honest at the dentist when you ask them about hygiene habits and the last time they came in? Make it easier for patients with this questionnaire. They can give you all the info you need in the time it takes them to brush their teeth.

With Typeform, you can customize everything

Change text, colors, and even logos to match look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 120+ tools including Slack, Zapier, and HubSpot.

Dental health history questionnaire FAQs:

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.