ADA Patient Health History Form - S50021
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ADA Patient Health History Form - S50021

ADA Patient Health History Form - S50021
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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. Includes questions related to dental history, medications and other substances, allergies, medical and surgical history, and general medical symptoms.

An additional Patient Screening Form is now included to assess patients for possible symptoms of COVID-19 in advance of their office visit. The form includes lines for pre-appointment and in-office responses that can be used to evaluate if a deeper discussion with the dentist is needed before treatment.

Children (S70721) and Spanish (S50121) forms are also available, as well as a downloadable form (S50021T) for posting on practice web sites.


Page count: 2 notepads of 100 sheets each, 8.5" x 11"

Copyright year: 2021


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