Health History Form Ada PDF Details

In the realm of dental care, accurate patient information is paramount to ensuring effective and safe treatment. The Health History Form provided by the American Dental Association (ADA) is a comprehensive document designed to collect essential health-related information from patients visiting a dental office. This form collects detailed personal information, including contact details, employment information, and specifics about the patient's dental and medical history, ensuring that dental professionals have a thorough understanding of the individual's health background. The form includes queries about a wide array of health concerns, ranging from tuberculosis exposure, dental problems like gum bleeding or sensitivity, to a broad spectrum of medical conditions such as joint replacements, allergies, and heart diseases. Additionally, it addresses lifestyle factors that can impact dental health, such as the use of tobacco, alcohol consumption, and drug use. Understanding the significance of such data, the form highlights the necessity of confidentiality, adhering strictly to laws safeguarding patient privacy. It is clear that the ADA's Health History Form plays a critical role in the dental care process, facilitating a tailored and informed approach to treatment that accounts for the intricate interplay between oral health and general well-being.

QuestionAnswer
Form NameHealth History Form Ada
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesamerican dental association health history form, ada health history form spanish, ada health history form template, ada health history form

Form Preview Example

Health History Form

A\D)A.

American Dental Association

( E-mail:

Today's Date:

www.ada.org

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.

Name:

 

 

Home Phone: Include area code

 

Business/CellPhone: Include area code

 

 

 

 

 

 

 

 

 

 

 

last

First

Middle

(

)

 

(

)

 

 

 

 

 

 

 

 

 

Zip:

 

Address:

 

 

City:

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

Mailina address

 

 

 

 

 

 

 

 

 

 

Occupation:

 

 

Height:

Weight:

 

Date of birth:

 

Sex: M

F

 

 

 

 

 

 

 

 

 

 

SS#or Patient ID:

EmergencyContact:

 

Relationship:

Home Phone:

 

Cell Phone:

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

Include area

codes

 

 

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

Your Name

 

Relationship

 

 

 

 

 

 

 

 

Do you have any of the following diseases or problems:

(Check DK if you Don't Know the answer TO the question)

Yes

NO OK

 

 

 

 

Active Tuberculosis

 

0

0

0

Persistent cough greater than

a 3 week duration

0

0

0

Cough that produces blood

 

0

0

0

Been exposed to anyone with

tuberculosis

0

0

0

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

Den t aI Infor mat ion For the following questions, please mark (X) your responses to the following questions.

 

Yes

NO

OK

Do your gums bleed when you brush or floss?

0

0

0

Are your teeth sensitive to cold, hot, sweets or pressure?

0

0

0

Does food or floss catch between your teeth?

0

0

0

Is your mouth dry?

0

0 0

Have you had any periodontal

(gum) treatments?

0

D D

Have you ever had orthodontic

(braces) treatment?

D D D

Haveyou had any problems associatedwith previous dental

 

 

treatment?

D D D

Is your home water supply fluoridated?

D D D

Do you drink bottled or filtered

water?

D D D

If yes, how often? Circle one: DAILY/ WEEKLY/ OCCASIONALLY

 

 

Are you currently experiencing

dental pain or discomfort?

D D D

What is the reason for your dental visit today?

 

 

Yes

NO OK

Do you have earaches or neck pains?

0

0

0

Do you have any clicking, popping

or discomfort in the jaw?

0

0

0

Do you brux or grind your teeth?

0

0

0

Do you have sores or ulcers in your

mouth?

0

0 0

Do you wear dentures or partials?

D D D

Do you participate in active recreational activities?

0

0 0

Have you ever had a serious injury to your head or mouth?

D D D

Date of your last dental exam:

What was done at that time?

Date of last dental x-rays:

How do you feel about your smile?

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

Yes NO OK

Yes NO OK

 

Are you now under the care of a physician?

D D D

Physician Name:

Phone:

Include area code

 

(

)

AddresslCitylStatelZi p:

 

Are you in good

health?

D D D

Hasthere been any change in your general health within

 

the past year?

D D D

If yes, what condition is being treated?

Have you had a serious illness, operation or been

hospitalized in the past 5 years? .....................................................

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription

or over the counter medicine(s)? ....................................................

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

D D D

D D D

Date of last physical exam:

C 2007 American Dental Association

Form 5S00

Me die aI Infor mat ion Please mark (X) your response TO indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer TO the question)

Yes

NO OK

Yes

NO OK

 

 

Do you wear contad

lenses?

0

0

0

Joint Replacement. Have you had an orthopedic total joint (hip,

 

 

 

knee, elbow,

finger)

replacement?

0

0

0

Date:

 

If yes, have you had any complications?

 

 

 

Are you taking or scheduled to begin taking either of the

 

 

 

medications, alendronate (Fosama~) or risedronate (Adonel")

 

 

 

for osteoporosis or Paget's disease?

0

0

0

Since 2001, were you treated or are you presently scheduled

 

 

 

to begin treatment with the intravenous bisphosphonates

 

 

 

(Aredia" or Zometa") for bone pain, hypercalcemia or skeletal

 

 

 

complications resulting from Paget's disease, multiple myeloma

 

 

 

or metastatic

cancer?

0

0

0

Date Treatment began:

 

 

 

Allergies - Are you allergic to or have you had a readion to:

Yes

NO

OK

To all yes responses, specify type of reaction.

 

 

 

local anesthetics

 

0

0

0

Aspirin

 

 

0

0

0

Penicillin or other antibiotics

0

0

0

Barbiturates,

sedatives, or sleeping pills

0

0

0

Sulfa drugs

 

 

0

0

0

Codeine or other narcotics

0

0

0

Do you use controlled substances (drugs)?

0

0

0

Do you use tobacco (smoking, snuff,

chew, bidis)?

0

0

0

If so, how interested are you in stopping?

 

 

 

(Circleone) VERYI SOMEWHATI NOTINTERESTED

 

 

 

Do you drink alcoholic beverages?

0

0

0

If yes, how much alcohol did you drink in the last 24 hours?

 

 

 

If yes, how much do you typically drink In a week?

 

 

 

WOMEN ONLY Are you:

 

 

 

 

Pregnant?

0

0

0

Number of weeks:

 

 

 

 

Taking birth control pills or hormonal

replacement?

0

0

0

Nursing?

0

0

0

 

 

Yes

NO

OK

Metals

 

0

0

0

latex (rubber)

 

0

0

0

Iodine

 

0

0

0

Hay fever/seasonal

 

0

0

0

Animals

 

0

0

0

Food

 

0

0

0

Other

 

0

0

0

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

NO

OK

 

 

Yes NO

OK

 

Yes

NO

OK

Artificial (prosthetic) heart valve

 

 

 

0

0

0

Autoimmune disease

0

0

 

0

Hepatitis, jaundice or

 

0

0

Previousinfedive endocarditis

..............................................................

 

 

 

0

0

0

Rheumatoid arthritis

0

0

 

0

liver disease

0

Damagedvalvesin transplanted heart

 

0

0

0

Systemiclupus erythematosus.0

0

 

0

Epilepsy

0

0

0

Congenital heart disease(CHD)

 

 

 

 

 

 

 

Asthma

0

0

 

0

Fainting spellsor seizures

0

0

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurological disorders

0

0

0

Unrepaired,cyanotic CHD

..............................................................

 

 

 

0

0

0

Bronchitis

0

0

 

0

Repaired(completely) in last 6 months

............................................

0

0

0

Emphysema

0

0

 

0

If yes, specify:

 

0

0

RepairedCHD with residualdefects

0

0

0

Sinustrouble

0

0

 

0

Sleepdisorder

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuberculosis

0

0

 

0

Mental health disorders

0

0

0

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended

 

Cancer/Chemotherapy/

 

 

 

 

 

Specify:

 

 

 

for any other form of CHD.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radiation Treatment

0

0

 

0

Recurrent Infections

0

0

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

NO

OK

 

Yes

NO

OK

Chest pain upon exertion

0

0

 

0

Typeof infection:

 

 

 

Cardiovasculardisease

0

0

 

0

Mitral valve prolapse

0

0

0

Chronic pain

0

0

 

0

Kidney problems

0

0

0

 

 

Night sweats

0

0

0

Angina

0

0

 

0

Pacemaker

0

0

0

Diabetes TypeI or

11 ......••••

0

0

 

0

 

 

 

Osteoporosis

0

0

0

Arteriosclerosis

0

0

 

0

Rheumaticfever

0

0

0

Eating disorder

0

0

 

0

 

 

Persistentswollen glands

 

 

 

Congestive heart failure

0

0

 

0

Rheumatic heart disease

0

0

0

Malnutrition

0

0

 

0

 

 

 

 

 

in neck

0

0

0

Damaged heart valves

0

0

 

0

Abnormal bleeding

0

0

0

Gastrointestinal disease

0

0

 

0

 

 

SevereheadacheS!

 

 

 

Heart attack

0

0

 

0

Anemia

0

0

0

G.E. Reflux/persistent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

migraines

0

0

0

Heart murmur

0

0

 

0

Blood transfusion

0

0

0

heartburn

0

0

 

0

 

 

Severeor rapid weight loss

0

0

0

Low blood pressure

0

0

 

0

If yes, date:

 

 

 

Ulcers

0

0

 

0

 

 

 

 

 

 

 

 

 

 

 

Sexuallytransmitted disease....

0

0

0

High blood pressure

0

0

 

0

Hemophilia

0

0

0

Thyroid problems

0

0

 

0

Other congenital heart

 

 

 

 

AIDSor HIV infection

0

0

0

Stroke

0

0

 

0

Excessiveurination

0

0

0

 

 

 

 

 

 

 

 

 

defects

0

0

 

0

Arthritis

0

0

0

Glaucoma

0

0

 

0

 

 

 

 

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

 

 

 

 

 

 

0

0

0

 

 

 

 

 

 

 

 

Name of physician or dentist

making

recommendation:

 

 

 

 

 

I

Phone:

 

 

 

 

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

 

 

 

 

 

 

 

0

0

0

.........................................................................

 

 

 

 

 

 

 

 

Pleaseexplain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

Signature

 

of

 

Patient/legal

 

Guardian:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COMPLETION BY DENTIST

Comments:---------

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american dental association health history form conclusion process shown (step 1)

2. Your next part is to fill out the next few blanks: Den t a I Infor mat, ion For the following questions, Yes No OK, Yes No OK, Do your gums bleed when you brush, in the jaw Do you brux, gum treatments D D Do you wear, Do you have earaches or neck pains, Is your mouth dry, Do you have any clicking popping, Have you had any problems, treatment Is your home water, D D D Date of your last dental exam, time, and If yes how often Circle one DAILY.

Filling out part 2 of american dental association health history form

3. This third section should be quite easy, Hasthere been any change in your, If yes what condition is being, If so please list all including, D D D andor diet supplements, Date of last physical exam, C American Dental Association, and Form S - every one of these blanks has to be completed here.

american dental association health history form completion process outlined (stage 3)

4. Completing Me die a I Infor mat ion Please, Check DK if you Dont Know the, to the question, Yes No OK, Do you use controlled substances, Joint Replacement Have you had an, If yes have you had any, hip, joint, Do you use tobacco smoking snuff, Circleone VERYI SOMEWHATI, Are you taking or scheduled to, Do you drink alcoholic beverages, Since were you treated or are you, and Date Treatment began is key in the next section - make sure to don't hurry and fill in each and every empty field!

Step no. 4 in filling in american dental association health history form

5. To wrap up your document, the particular part has some additional fields. Filling in Unrepaired cyanotic CHD, Except for the conditions listed, form of CHD, Autoimmune disease Rheumatoid, Yes No OK, Cardiovasculardisease Angina, Other congenital heart, defects, Mitral valve prolapse Pacemaker, If yes date, Radiation Treatment Yes No OK, heartburn Ulcers Thyroid, Hepatitis jaundice or liver, Specify, and Typeof infection should finalize the process and you will be done very quickly!

Filling out part 5 in american dental association health history form

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