Health History Form

Please correct the errors described below.

ADA American Dental Association ®

America's leading advocate for oral health

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

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

Do you have any of the following diseases or problems? (Select DK if you Don’t Know the answer to the the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please select your responses to the following questions.

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems.

Physician Name

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(Select DK if you Don’t Know the answer to the question)

WOMEN ONLY, Are you:

Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

Please select your response to indicate if you have or have not had any of the following diseases or problems

Congenital heart disease (CHD)

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

Name of physician or dentist making recommendation:

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

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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Legal Guardian:

Signature of Dentist:

FOR COMPLETION BY DENTIST

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