ADA Health History Form (Mobile-Friendly)

Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

ADA American Dental Association®

America's leading advocate for oral health

Form S500

Email *

Today’s Date *

Patient Identification

Name — Last *

First *

Middle

Home Phone (include area code)

Business/Cell Phone (include area code) *

Address (mailing address)

City

State

Zip

Occupation

Height

Weight

Date of Birth *

Sex

M F

SS# or Patient ID

Emergency Contact

Relationship

Emergency Contact Home Phone (include area code)

Emergency Contact Cell Phone (include area code)

If completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Dental Information

Please mark (X) your responses to the following questions.

What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information

Please mark (X) to indicate if you have or have not had any of the following diseases or problems.

Are you now under the care of a physician?

Yes No DK

Physician Name

Phone (include area code)

Address/City/State/Zip

Date of last physical exam

Date of your last dental exam

What was done at that time?

Date of last dental x-rays

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes No DK

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes No DK

If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:

Additional Medical Information (Page 2)

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No DK

Name of physician or dentist making recommendation

Phone (include area code)

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No DK

Please explain

Women Only

Allergies

To all “Yes” responses, specify type of reaction.

Allergen / Item	Reaction (if Yes)	Yes / No / DK

Medical Conditions

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Cardiac conditions for which antibiotic prophylaxis is indicated

Except for the conditions listed below, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Certification & Signatures

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient / Legal Guardian *

Date *

Signature of Dentist

Date

For completion by dentist

Comments

Patient Identification

Do you have any of the following diseases or problems?

Dental Information

Medical Information

Additional Medical Information (Page 2)

Women Only

Allergies

Medical Conditions

Cardiac conditions for which antibiotic prophylaxis is indicated

Certification & Signatures

Signature of Patient / Legal Guardian *

Signature of Dentist

For completion by dentist