DSU DENTAL HYGIENE CLINIC

INSTRUCTIONS
To receive treatment in this clinic, you must answer all questions on this history form. The questions asked relate directly to the safe and effective treatment you are to receive. Give honest answers to the best of your ability. If you are unsure of the questions, unsure of your answer, or whether the question relates to your medical condition, leave the answer blank and discuss it with your student dental hygienist. Some of the questions may not relate to your medical condition; in that event, you are to write “N/A” (not applicable) in the space provided. To properly evaluate your current health status, it may be necessary for the clinic to contact your physician.

PERSONAL

NAME: ______M / F BIRTHDATE: ______
(LAST) (FIRST) (M.I.)

STREET ADDRESS: ______
(STREET ADDRESS) (CITY) (STATE) (ZIP)

LEGAL GUARDIAN: ______OCCUPATION: ______(PLEASE CIRCLE): SINGLE / MARRIED

HOME PHONE: ______WORK PHONE: ______CELL PHONE: ______

(PLEASE CIRCLE, IF APPLICABLE): MEDICAID DSU STUDENT DSU FACULTY/STAFF SDH FAMILY MEMBER

EMERGENCY CONTACT (NAME AND PHONE NUMBER): ______

DISCLOSURE

DIXIE STATE UNIVERSITY DENTAL HYGIENE PROGRAM COMPLIES WITH THE HEALTH INFORMATION PRIVACY ACT (HIPAA). A COPY OF THE HEALTH INFORMATION PRIVACY ACT HAS BEEN PROVIDED.

PHYSICIAN(S)/DENTIST (S)

PHYSICIAN NAME / ADDRESS/PHONE / DATE OF LAST VISIT
DENTIST NAME / ADDRESS/PHONE / DATE OF LAST VISIT

MEDICAL/DENTAL HISTORY

CIRCLE ANSWERS: Y=YES OR N=NO

Y N 1. Are you allergic to Latex? ______

Y N 2. Have you been hospitalized in the last two (2) years? If so, why? ______

Y N 3. Have you been under a physician’s care (i.e., annual physicals, emergency care) during the last two (2) years?

______

Y N 4. Do you have ANY known drug, medication, or material allergy?

Please list: ______

Y N 5. Have you ever had excessive bleeding requiring special treatment or are you on blood thinners?

______

Y N 6. Do you use tobacco in any form? (circle) cigar, pipe, cigarette, chew.

Y N 7. Has your physician ever said you have cancer or a tumor? If so, when & what kind? ______

Y N 8. WOMEN: Are you pregnant? If so, what trimester? ______

9. Circle any of the following conditions that apply to you:

Y N A. Unstable Angina

Y N B. Active Hepatitis: Type ______

Y N C. Active Tuberculosis

Y N D. Heart Attack or Stroke within 6 months

Y N E. Hemodialysis or Hemophilia

Y N F. Herpetic lesions with tissue not intact

Y N G. Uncontrolled Epilepsy

10. Circle any of the following dental problems and treatments you have had or currently have:

Y N A. AIDS, to include a statement of the T-cell count

Y N B. Corticosteroid/Immunosuppressive Therapy

Y N C. Hepatitis Carrier: Type ______

Y N D. Prosthetic Heart Valve

Y N E. Complex Cyanotic Congenital Heart Disease

Y N F. Surgically Constricted systemic Pulmonary Shunts or Conduits

Y N G. Mitral Valve Prolapse

Y N H. Weight Bearing Joint or Hip Replacement

Y N I. Renal Transplant

Y N J. Vital Signs beyond Normal Limits without Indicated Medical Condition or Medical Clearance

Y N K. Radiation Therapy within 6 Months

Y N L. Ever Taken Phen Fen

11. Circle any of the following conditions or treatments which you have had or do have at present:

Heart Complications / Back Complications / Leukemia / Psychiatric Care
Heart Attack / Fainting / Dizziness / Anemia / Eating Disorder
Heart Murmur / Cold Sores / Herpes / Bruise Easily / Chemical Dependency
Rheumatic Fever / Hay Fever / Chemotherapy / Alcoholism
Heart Pacemaker / Sinus Problems / Radiation Therapy / Anxiety
Stroke / Persistent Cough / STD / Liver Disease
Hemophilia / Asthma / Bronchitis / HIV Positive / Hepatitis: Type _____
Epilepsy or Seizure / Allergies or Hives / Ulcers / Rheumatiod Arthritis
Kidney Disease / Thyroid Disease / Diabetes / Other: ______

12. Have you taken or are you now taking any of the following:

Y N A. Antiobiotics

Y N B. Anticoagulants (Blood Thinners)

Y N C. High Blood Pressure Medication

Y N D. Cortisone (Steroids)

Y N E. Tranquilizers

Y N F. Aspirin

Y N G. Insulin or Diabetes Medication

Y N H. Nitroglycerin

Y N I. Antihistamines

Y N L. Bone Density Medication (Fosamax, Boniva, Reclast, etc.)

13. Circle any of the following conditions or treatments which you have had or do have at present:

Dental Injury / Dental/ Jaw Surgery / Grinding / Jaw Pain / Bleeding Gums
Dental Pain / Loose Teeth / Difficulty Chewing / Breathe Through Mouth
Orthodontic Treatment / Endodontic Treatment / Difficulty Swallowing / Nail Biting, Thumb Sucking, etc.
Bad Breath / Dental Implant Surgery / Periodontal Therapy / Other: ______

14. Please list all medications, supplements, and herbs you are currently taking.

Drug Name / Reason for Medication

Y N 15. Do you have any dental concerns at this time? If so, explain. ______

Y N 16. Are you nervous about receiving dental care? If so, explain. ______

Y N 17. Have you have a bad dental experience? If so, explain. ______

Y N 18. Do you eat or drink sweets between meals?

Y N 19. Do hot, cold or sweet beverages or food cause discomfort?

Y N 20. Oral habit (clenching, grinding, thumb-sucking, nail biting, etc.)

I hereby give permission to release information on this form to my physician, and certify that the information contained herein is correct to the best of my knowledge:


SIGNATURE: ______DATE: ______

PARENT OR GUARDIAN: ______DATE: ______