Updated Adult Health & Social History

To be updated every year

Patient Name: Phone: Email:
1) Does the patient have any health problems (past or present)?
Yes No
If yes, explain
2) Is the patient currently seeing a physician for any problem?
Yes No
If yes, explain
3) Does the patient take any medications?
Yes No
If yes, explain
4) Does the patient have any allergy to any food, medicine or materials (e.g. antibiotics, latex)?
Yes No
If yes, explain
5) Has the patient ever had a heart murmur, heart defect or rheumatic fever?
Yes No
If yes, explain
6) Has the patient ever been injured, hospitalized or received surgery?
Yes No
If yes, explain
7) Ever taken oral bisphosphonates (i.e. Fosamax,Actonel)?
Yes No
8) Currently pregnant?
Yes No
9) Currently nursing?
Yes No
10) Has the patient been pregnant in the past?
Yes No
11) Has the patient ever had a blood transfusion?
Yes No

Has the patient ever had any of the following?

Yes No
Breathing problems or asthma?
Blood problems such as sickle cell anemia?
AIDS or HIV infection?
Frequent cough or tuberculosis (T.B.)?
Stomach, bowel problems or gastric reflux?
Endocrine orhormone problems?
Hives or skin rash?
General anesthesia?
Yes No
Airway, tonsil or adenoid problems?
Easy bleeding on brushing?
Frequent headaches?
Hepatitis or liver problems?
Diabetes, excessive thirst or urination?
Kidney problems?
Seizures, dizziness, fainting spells or epilepsy?
Birth defect or disability?
1) Does the patient have or had any disease or condition not listed above?
Yes No
2) Does anyone in the immediate family have history of allergies, diabetes, etc.?
Yes No
3) Did the patient have any health problems or illnesses when younger or at birth?
Yes No
4) Does the patient have any emotional, behavior or learning problems (e.g. ADD/ADHD)?
Yes No
5) Has the patient related well to previous treatments?
Yes No
Name of Patient's Primary Care Physician: Date of Last Physical:
To the best of my knowledge, the above information is complete and accurate. Providing incorrect information can be dangerousto my health and I will inform the dental office of any changes in my medical status. I authorize the dentist to release any information, including the diagnosis and records of any treatment or examination rendered during the period of such dental care to third party payers and/or other health practitioners.
Patient's Name:
Signature:
Date:
For Office Use Only: Reviewed By: ________________________
Provider's Name: ________________________
Signature: ________________________ Date: ________________________
Please enter code above in the field below.