Pt ID #
_________________
Medical/Dental History Form
Office Use Only
SLCC has written policies on this clipboard to protect your privacy. Please read them and if you have any questions,
please ask. The Medical/Dental History form should be answered completely and as accurately as possible. The
information will allow us to provide appropriate care for you. Thank you for being a patient in our student dental hygiene
clinic.
Please Fill Out This Form Completely
Last Name ______________________________ First Name ________________________________ Middle Initial __________
Gender: M F
Address_______________________________________________________________________ Date of Birth: ______________
Street
City
State
Zip
Phone (h) ________________ Phone (w) _________________Phone (c) _____________________ email __________________
How do you prefer that we contact you? ___________________________Occupation: __________________________________
Emergency Contact __________________________________Relationship ___________________ Phone _________________
Dental History
Dentist’s Name ______________________________ City/State __________________________ Phone ___________________
A. Do your gums bleed when you brush or floss?
B. Are your teeth sensitive to hot, cold, sweets, pressure?
C. Does food or floss catch between your teeth?
D. Is your mouth often dry?
E. Have you had periodontal (gum) treatment?
F.
Have you had orthodontic treatment (braces)?
G. Have you had a serious injury to your head or mouth?
H. Do you have clicking, popping, or other discomfort in
your jaw?
I. Have you had any problems related to dental
treatment?
J. Are you currently experiencing dental pain or
discomfort?
U. What is the reason for your visit today?
Yes
No
















K. Do you have any sores or ulcers in your mouth?


S. Date of your last dental radiographs (x-rays):


T. How do you feel about your smile?
L. Do you participate in energetic sports or activities?
M. Do you experience frequent ulcers in your mouth?
N. Do you brux (grind) your teeth?
O. Do you wear dentures or partial dentures?
P. Is your home water fluoridated?
Q. Do you frequently drink bottled or filtered water?
Yes
No














Yes
No














R. Date of your last dental exam?
Medical History
Yes
No
1. Do you consider yourself in good health?


2. Are you currently under the care of a physician?
If yes, what condition is being treated?


7. Has there been any change in your general health in
the past year?
8. Have you had a serious illness, operation, or been
hospitalized in the past five years?
If yes, what was the illness or problem?
3.
Date of your last physical exam?
9.
4.
Have you taken any diet drugs such as Pondimin,
Redux, or Phen-Fen?


5.
Were you treated or are you presently scheduled to
begin treatment with intravenous bisphosphonates?
For what purpose?


Do you use controlled substances/recreational drugs?
If yes, what and how often?
10. Do you use tobacco?
Please circle which form(s): smoke
snuff
chew
How frequently do you use tobacco?
Are you interested in learning how to quit?
Date treatment began or will begin:
6.
Are you taking cortisone medication?
11. Do you use alcohol?


If yes, how much do you typically drink in a week?
If yes, how much in the past 24 hours?
If yes, when did you last use?
WOMEN ONLY:
12. Are you taking birth control pills or hormone therapy?
13. Are you lactating (nursing)?




14. Are you pregnant?
If pregnant, number of weeks?
 No  Have you ever had a positive TB skin test?
Yes  No 
If yes, when?
16. Have you ever had a joint replacement
Yes  No 
What joint?
If yes, did you have any complications or infections?
17. Please circle any of the following that you are allergic to or had a reaction to, and specify the type of reaction:
Local anesthetics
Penicillin or other antibiotics
Aspirin or NSAID
Barbiturates, sedatives, sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex
Iodine
Hay fever/seasonal allergies
Other
18. Drugs:
Please list any prescription or over the counter medicines that you are currently taking (include vitamins, natural medicines,
homeopathic or
herbal supplements or remedies).
Prescription
Over-the-Counter (OTC)
15. Do you have or have you had tuberculosis? Yes
Circle if you have or have had any of the following:
19. Damaged/artificial heart
31. Anemia
valves
20. Congenital heart defects
32. AIDS or HIV
21. Cardiovascular disease
33. Arthritis
22. Angina or chest pain
34. Autoimmune disease
23. Infective endocarditis
35. Lupus erythematosus
24. Congestive heart failure
36. Asthma
25. MI (Heart attack)
37. COPD
26. High blood pressure
38. Emphysema
27. CVA (Stroke)
39. Sinus problems
28. Abnormal bleeding
40. Persistent cough
29. Hemophilia
41. Chronic pain
30. Pacemaker or Implantable
42. Diabetes Type I
Cardioverter Defibrillator (ICD) 43. Diabetes Type II
44. Eating disorder
12. Mental disorder
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
If yes, specify_______________
13. Recurrent infections
If yes, specify_______________
14. Kidney problems/hemodialysis
15. Osteoporosis
16. Persistent swollen neck glands
17. Wheezing/shortness of breath
18. Significant/rapid weight change
19. Sexually transmitted infection
20. Cold sores or fever blisters
21. Excessive urination, thirst,
hunger
Special diet
Gastrointestinal disease
GERD/Reflux
Ulcers
Thyroid problems
Glaucoma
Hepatitis, liver disease
Epilepsy
Physical limitation(s)
Sleep disorder
Cancer, chemotherapy,
radiation
66. Has a physician recommended that you take antibiotics prior to professional oral health care (dental work)?
Yes
67. Do you have any disease, condition, or problem not listed on this form that you think we should know about?
Please explain?
Yes


No
No


Physician’s Name _____________________________ City/State _______________________________Phone _______________
I understand the importance of complete and truthful medical and dental information and that incorrect information could pose a serious threat to
my health. To the best of my knowledge, the answers to the preceding questions are true and correct. I will not hold the Salt Lake Community
College (SLCC) or any person who provides dental hygiene or dental services responsible for any actions that they take or do not take because of
any errors or omissions that I may have made in the completion of this form. I consent to the release of medical/dental information to my dentist,
physician, or other healthcare professional if requested.
Further, if I ever have any change in my health, or if my medications change, I will inform my student dental hygienist or a SLCC faculty
member at my next appointment without fail. I hereby grant permission to be treated by students and faculty of SLCC.
__________________________ _____________ __________________________
Signature of Patient/Legal Guardian
Date
Date
________________________________________________________
Signature of Clinical Instructor Signature/Number
Signature of Student/Number
________________________
Date
Note: Your signature below verifies that any necessary changes to the history for subsequent appointments have been noted and dated on the
form. A new medical/dental history form must be completed every three years.
a. Date: _______ Yes
No
Patient Signature ______________________________ Student ____________________ CI Init
b. Date:
Yes
No
Patient Signature ______________________________ Student ____________________ CI Init
c. Date:
Yes
No
Patient Signature ______________________________ Student ____________________ CI Init
d. Date:
Yes
No
Patient Signature ______________________________ Student _____________ ____ __ CI Init
e. Date:
Yes
No
Patient Signature ______________________________ Student ____________________ CI Init
f. Date:
Yes
No
Patient Signature ______________________________ Student ________________ ___ CI Init