Health History Form

1
This is a secure file submission area for the ADA Health History form on our website. Please upload your completed form below and we'll review it!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
2
Occupation* This field is required.
3
Height* This field is required.
4
Weight* This field is required.
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Sex* This field is required.
Male
Female
7
SSN or Patient ID* This field is required.
8
Emergency Contact* This field is required.
9
Relationship to patient* This field is required.
10
Emergency Contact Home Phone Number* This field is required.
Area Code
Phone Number
11
Emergency Contact Cell Phone Number* This field is required.
Area Code
Phone Number
12
If you are completing this form for another person, what is your relationship to that person?* This field is required.
Put "N/A" if this does not apply
13
Relationship* This field is required.
Put "N/A" if this does not apply
14
Do you have any of the following diseases or patterns?* This field is required.
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
Not completely certain about experiencing the above
None of the above
Other
15
Do your gums bleed when you brush or floss?* This field is required.
Yes
No
Not sure
16
Are your teeth sensitive to cold, hot, sweets or pressure?* This field is required.
Yes
No
Not sure
17
Is your mouth dry?* This field is required.
Yes
No
Not sure
18
Have you had any periodontal (gum) treatments?* This field is required.
Yes
No
Not sure
19
Have you ever had orthodontic (braces) treatment?* This field is required.
Yes
No
Not sure
20
Have you had any problems associated with previous dental treatment?.* This field is required.
Yes
No
Not sure
21
Is your home water supply fluoridated?* This field is required.
Yes
No
Not sure
22
Do you drink bottled or filtered water?* This field is required.
Yes
No
Not sure
23
Do you drink bottled or filtered water?* This field is required.
Yes
No
Not sure
24
If yes, how frequently?
Daily
Weekly
Occasionally
25
Are you currently experiencing dental pain or discomfort?* This field is required.
Yes
No
Not sure
26
Do you have earaches or neck pains?* This field is required.
Yes
No
Not sure
27
Do you have any clicking, popping or discomfort in the jaw?* This field is required.
Yes
No
Not sure
28
Do you brux or grind your teeth?* This field is required.
Yes
No
Not sure
29
Do you have sores or ulcers in your mouth?* This field is required.
Yes
No
Not sure
30
Do you wear dentures or partials?.* This field is required.
Yes
No
Not sure
31
Do you participate in active recreational activities?* This field is required.
Yes
No
Not sure
32
Have you ever had a serious injury to your head or mouth?* This field is required.
Yes
No
Not sure
33
Date of your last dental exam: * This field is required.
34
What was done at that time? * This field is required.
35
Date of last dental x-rays:* This field is required.
36
What is the reason for your dental visit today?* This field is required.
37
How do you feel about your smile? * This field is required.
38
Are you now under the care of a physician?* This field is required.
Yes
No
Not sure
39
Physician Name:* This field is required.
40
Physician's Phone Number* This field is required.
Area Code
Phone Number
41
Physician's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
42
Are you in good health?* This field is required.
Yes
No
Not sure
43
Has there been any change in your general health within the past year?* This field is required.
Yes
No
Not sure
44
If yes, what condition is being treated?
45
Date of last physical exam:
46
Have you had a serious illness, operation, or been hospitalized in the past 5 years?* This field is required.
Yes
No
Not sure
47
If yes, what was the illness or problem?
48
Are you taking or have you recently taken any prescriptionor over the counter medicine(s)?* This field is required.
Yes
No
Not sure
49
If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:
50
Do you wear contact lenses?* This field is required.
Yes
No
Not sure
51
Joint Replacement: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?* This field is required.
Yes
No
Not sure
52
If yes, what was the date of the replacement?
53
If yes, have you had any complications?
54
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?* This field is required.
Yes
No
Not sure
55
Since 2001, were you treated or are you presently scheduled to begintreatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?* This field is required.
Yes
No
Not sure
56
If yes, what date did treatment begin?
57
Do you use controlled substances (drugs)?* This field is required.
Yes
No
Not sure
58
If yes, how much do you typically drink in a week?
59
Women only: are you pregnant?* This field is required.
Yes
No
Not sure
N/A
60
If yes, how many weeks?
61
Women only:* This field is required.
Yes
No
Not sure
N/A
62
Women only: are you nursing?* This field is required.
Yes
No
Not sure
N/A
63
Allergies: Are you allergic to or have you had a reaction to: L* This field is required.
Yes
No
Not sure
64
If yes, be specific/describe reaction.
65
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
66
If yes, be specific/describe reaction.
67
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
68
If yes, be specific/describe reaction.
69
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
70
If yes, be specific/describe reaction.
71
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
72
If yes, be specific/describe reaction.
73
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
74
If yes, be specific/describe reaction.
75
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
76
If yes, be specific/describe reaction.
77
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
78
If yes, be specific/describe reaction.
79
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
80
If yes, be specific/describe reaction.
81
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
82
If yes, be specific/describe reaction.
83
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
84
If yes, be specific/describe reaction.
85
Allergies: Are you allergic to or have you had a reaction to:* This field is required.
Yes
No
Not sure
86
If yes, be specific/describe reaction.
87
Any other allergies we should be aware of?* This field is required.
88
Other health conditions: Artificial (prosthetic) heart valve:* This field is required.Please mark yes if you have experienced the listed condition.
Yes
No
Not sure
89
Other health conditions:* This field is required.
Yes
No
Not sure
90
Other health conditions:* This field is required.
Yes
No
Not sure
91
Other health conditions:* This field is required.
Yes
No
Not sure
92
Other health conditions:* This field is required.
Yes
No
Not sure
93
Other health conditions:* This field is required.
Yes
No
Not sure
94
Other health conditions:* This field is required.
Yes
No
Not sure
95
Other health conditions:* This field is required.
Yes
No
Not sure
96
Other health conditions:* This field is required.
Yes
No
Not sure
97
Other health conditions:* This field is required.
Yes
No
Not sure
98
Other health conditions:* This field is required.
Yes
No
Not sure
99
Other health conditions:* This field is required.
Yes
No
Not sure
100
Other health conditions:* This field is required.
Yes
No
Not sure
101
Other health conditions:* This field is required.
Yes
No
Not sure
102
Other health conditions:* This field is required.
Yes
No
Not sure
103
Other health conditions:* This field is required.
Yes
No
Not sure
104
Other health conditions:* This field is required.
Yes
No
Not sure
105
Other health conditions:* This field is required.
Yes
No
Not sure
106
Other health conditions:* This field is required.
Yes
No
Not sure
107
Other health conditions:* This field is required.
Yes
No
Not sure
108
Other health conditions:* This field is required.
Yes
No
Not sure
109
Other health conditions:* This field is required.
Yes
No
Not sure
110
Other health conditions:* This field is required.
Yes
No
Not sure
111
If yes, date:
112
Other health conditions:* This field is required.
Yes
No
Not sure
113
Other health conditions:* This field is required.
Yes
No
Not sure
114
Other health conditions:* This field is required.
Yes
No
Not sure
115
Other health conditions:* This field is required.
Yes
No
Not sure
116
Other health conditions:* This field is required.
Yes
No
Not sure
117
Other health conditions:* This field is required.
Yes
No
Not sure
118
Other health conditions:* This field is required.
Yes
No
Not sure
119
Other health conditions:* This field is required.
Yes
No
Not sure
120
Other health conditions:* This field is required.
Yes
No
Not sure
121
Other health conditions:* This field is required.
Yes
No
Not sure
122
Other health conditions:* This field is required.
Yes
No
Not sure
123
Other health conditions:* This field is required.
Yes
No
Not sure
124
Other health conditions:* This field is required.
Yes
No
Not sure
125
Other health conditions:* This field is required.
Yes
No
Not sure
126
Other health conditions:* This field is required.
Yes
No
Not sure
127
Other health conditions:* This field is required.
Yes
No
Not sure
128
Other health conditions:* This field is required.
Yes
No
Not sure
129
Other health conditions:* This field is required.
Yes
No
Not sure
130
Other health conditions:* This field is required.
Yes
No
Not sure
131
Other health conditions:* This field is required.
Yes
No
Not sure
132
Other health conditions:* This field is required.
Yes
No
Not sure
133
Other health conditions:* This field is required.
Yes
No
Not sure
134
Other health conditions:* This field is required.
Yes
No
Not sure
135
Other health conditions:* This field is required.
Yes
No
Not sure
136
Other health conditions:* This field is required.
Yes
No
Not sure
137
Other health conditions:* This field is required.
Yes
No
Not sure
138
Other health conditions:* This field is required.
Yes
No
Not sure
139
If yes, specify:
140
Other health conditions:* This field is required.
Yes
No
Not sure
141
Other health conditions:* This field is required.
Yes
No
Not sure
142
Other health conditions:* This field is required.
Yes
No
Not sure
143
If yes, specify:
144
Other health conditions:* This field is required.
Yes
No
Not sure
145
Type of infection:
146
Other health conditions:* This field is required.
Yes
No
Not sure
147
Other health conditions:* This field is required.
Yes
No
Not sure
148
Other health conditions:* This field is required.
Yes
No
Not sure
149
Other health conditions:* This field is required.
Yes
No
Not sure
150
Other health conditions:* This field is required.
Yes
No
Not sure
151
Other health conditions:* This field is required.
Yes
No
Not sure
152
Other health conditions:* This field is required.
Yes
No
Not sure
153
Other health conditions:* This field is required.
Yes
No
Not sure
154
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?* This field is required.
Yes
No
Not sure
155
Name of physician or dentist making recommendation:
156
Phone Number
Area Code
Phone Number
157
Do you have any disease, condition, or problem not listed above that you think I should know about?* This field is required.
Yes
No
Not sure
158
If yes, please explain:
159
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.* This field is required.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 completing this form.
Clear
160
Date of signature* This field is required.
Date
Year
Month
Day
Should be Empty: