Adult Health History Form

Download and print the Adult Health History Form (PDF) or complete and submit the form below.

Adult Health History Form - Dalseth Dental

As required by law, our office adheres to written policies and procedures to protect the privacy of information we create, receive or maintain. Your answers are for our records 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.

Phone
This field is for validation purposes and should be left unchanged.
Today's Date
MM slash DD slash YYYY
Patient Information
Patient's Name
First Last
Date of Birth
MM
DD
YYYY
Age
Sex
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email
How would you prefer to be contacted for appointment confirmation?
How did you hear about our office?
Spouse's Name
First Last
Emergency Contact Information (include name and phone number)
Person Responsible for Account
Your Name (If child please fill out both parents)
First Last
Employer
Position
Business Phone
Dental Insurance Name and Address
Group # (required)
Employee ID # (required)
Insurance ID or Social Security Number
Birthdate
MM
DD
YYYY
Spouse's Name (If child please fill out both parents)
First Last
Employer
Position
Dental Insurance Name
Group or Employee Number (required)
Dental Information
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you had any orthodontic (braces) treatments?
Have you had problems associated with previous dental treatments?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Are you currently experiencing dental pain or comfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Have you ever had a serious injury to your head or mouth?
Have you (the parent/guardian) or the patient had any of the following diseases or problems? (If so, please stop and contact our office)
- Active Tuberculosis
- Persistent cough greater than a 3 week duration
- Cough that produces blood
Date of You Last Dental Exam
MM
DD
YYYY
What was done at that time?
Reason for Dental Visit Today
Medical Information
Are you now under the care of a physician?
Physician's Name
Physician's Phone
Has there been any change in your general health within the past year?
Is yes, what is being treated?
Date of Last Physical Exam
MM
DD
YYYY
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Is yes, what is illness or problem?
Are you taking or have recently taken any prescriptions or over the counter medicine(s)?
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:
Do you wear contact lenses?
Have you had total (hip, knee, elbow, finger) replacement?
Date
MM
DD
YYYY
Any Complications?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamex) or risedronate (Actonel) for osteoporosis or Paget's Disease?
Since 2001, were you treated or presently schedule to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) or bone pain, hypercalcemia or skeletal complications resulting from Paget's Disease, multiple myeloma or metastatic cancer?
History of Chemical Dependency?
Do you use tobacco (smoke, snuff, chew, bidis)?
Are you interested in quitting?
Do you drink alcoholic beverages?
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 - Are you pregnant?
Number of Weeks?
Taking birth control pills or hormonal replacement?
Are you nursing?
Are you allergic to Aspirin?
Are you allergic to Penicillin or other antibiotics?
Are you allergic to barbiturates, sedatives, or sleeping pills?
Are you allergic to sulfa drugs?
Are you allergic to codeine or other narcotics?
Are you allergic to metal?
Are you allergic to latex (rubber)?
Are you allergic to Iodine?
Do you have hay fever/seasonal allergies?
Are you allergic to animals?
Are you allergic to food?
Are you allergic to other?
If yes, list reaction to above allergies:
Have you had an artificial (prosthetic) heart valve?
Have you had previous infective endocarditis?
Have you had damaged valves in transplanted heart?
Have you had unrepaired, cyanotic Congenital Heart Disease?
Have you had repaired, Congenital Heart Disease in the last 6 months?
Have you had repaired, Congenital Heart Disease with residual effects?
Have you had cardiovascular disease?
Have you had angina?
Have you had high cholesterol?
Have you had congestive heart failure?
Have you had damaged heart valves?
Have you had a heart attack?
Have you had a heart murmer?
Have you had low blood pressure?
Have you had high blood pressure?
Have you had other congenital heart defects?
Have you had mitral valve prolapse?
Have you had a pacemaker?
Have you had rheumatic fever?
Have you had rheumatic heart disease?
Have you had abnormal bleeding?
Have you had anemia?
Have you had a blood transfusion?
If yes, date?
MM
DD
YYYY
Have you had hemophilia?
Have you had AIDS or HIV infection?
Have you had Arthritis?
Have you had an autoimmune disease?
Have you had rheumatoid arthritis?
Have you had systemic lupus erythematosus?
Have you had asthma?
Have you had bronchitis?
Have you had emphysema?
Have you had sinus trouble?
Have you had tuberculosis?
Have you had cancer/chemotherapy/radiation treatment?
Have you had chest pain upon exertion?
Have you had chronic pain?
Have you had diabetes type I or II?
Have you had an eating disorder?
Have you had malnutrition?
Have you had gastrointestinal disease?
Have you had G.E. reflux/persistent heartburn?
Have you had ulcers?
Have you had thyroid problems?
Have you had a stroke?
Have you had glaucoma?
Have you had hepatitis, jaundice or liver disease?
Have you had epilepsy?
Have you had fainting spells or seizures?
Have you had mental health disorders?
Specify:
Have you had recurrent infections?
Type of infection
Have you had kidney problems?
Have you had night sweats?
Have you had osteoporosis?
Have you had persistent swollen glands in neck?
Have you had severe headaches or migraines?
Have you had severe or rapid weight loss?
Have you had a sexually transmitted disease?
Have you had excessive urination?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of Physician or Dentist making recommendation:
Do you have a disease, condition, or problem not listed above that you think we should know about?
Please explain:
Signature
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, of 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. I also understand that I am responsible (regardless of my insurance status) for the balance on my account for my professional services rendered. ASSIGNMENT OF BENEFITS: I authorize insurance benefit payment to be made directly to Dalseth Family and Cosmetic Dentistry, PA,
Signature of Patient or Parent/Legal Guardian:
Date
MM slash DD slash YYYY
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Adult Health History Form - Dalseth Dental

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