Patient Registration and Forms | American Dental Association - ADA
The American Dental Association (ADA) offers a comprehensive health history form, for adults or children in both English and Spanish, that covers both medical and dental issues. The form is available in a digital, downloadable version or in print.
Medical/Dental Health History | American Dental Association - ADA
Sample health history forms are available through the American Dental Association’s (ADA) Department of Product Development and Sales and can be ordered online. The document is available in both English and Spanish; different forms are available for children and adults.
Date of your last dental exam: What was done at that time? your response 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?.........................................................
ADA Patient Health History Form - American Dental Association
Learn more about the Patient Health History Form. Order today.
Child Health/Dental History Form ADA American Dental Association America's leading advocate for oral health Patient's Name LAST FIRST INITIAL Parent's/Guardian's Name Address PO OR MAILING ADDRESS Phone Homo Work Have you (the parent/guardian) or the patient had any of the following diseases o 1 , Active Tuberculosis, 2.
Use the 2021 edition of the ADA Patient Dental and Medical Health History Information Form to collect pertinent health information and history from your patients before treatment. Clear two-sided layout and simple wording make form completion easy.
Have you had a serious/difficult problem associated with any previous dental treatment? How would you describe your current dental problem? What was done at that time? How do you feel about the appearance of your teeth? If you answer yes to any of the 3 items below, please stop and return this form to the receptionist.
This 2012 edition of the ADA Health History Form reflects the latest AHA premedication guidelines. Clear 2-sided layout and simple wording make form completion easy. Just download the PDF form and print no shipping or handling charges!
Have you been under the care of a medical doctor during the past two years? Yes No Medical Doctor’s Name: _____ Address: _____ Telephone: _____
Feb 23, 2016 · 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.