CHABOT COLLEGE – DENTAL HYGIENE PROGRAM
MEDICAL/DENTAL HISTORY
Patient’s Name:
Sex:  Male
(Last)
 Female
 New Patient
(First)
Height:
Weight:
 Returning Patient
Date of Birth:
Please Answer All Questions
Medical History
Your Primary Physician’s Name:
_______ City:
Address:
Is more than one doctor treating you? Yes No
_______
Phone: (
_______
Zip:
Address:
State:
)
For What?
Doctor’s Name:
City:
Date of last physical exam:
Zip:
Phone: (
_______
)
Please list all medications you are currently taking:
______________
_______
Have you ever had an adverse reaction to any of the following?
 Penicillin or other antibiotics  Aspirin, Codeine or other pain medications  Novocain, Lidocaine, or other anesthetics
Have you been hospitalized, had a serious illness, or had any kind of surgery in the past 5 years?  Yes  No If yes, what for? _____________
(Women: Are you pregnant?  Yes  No Nursing? Yes  No Taking oral contraception?  Yes  No)
Check () any of the following that apply to you:
 Recent weight loss, fever,
 Hemophilia
 Contact lenses
 AIDS
 Hepatitis
 Diabetes
 Alcoholism
night sweats
 Respiratory Disease
 Hernia Repair
 Diabetes
 Allergies
 Rheumatic Fever
 Herpes
 Diarrhea, constipation,
 Anemia
 High Blood Pressure
 Angina/Chest Pain
 Scarlet Fever
blood in stool
 Difficulty swallowing
 Sexually Transmitted
 HIV positive
 Arthritis, Rheumatism
 Difficulty urinating, blood
 Jaundice
 Artificial Heart Valves
Diseases
 Shortness of breath
 Joint pain, stiffness
in urine
 Artificial Joints
 Dry mouth
 Skin Rashes
 Joint Surgery
When placed?
 Emphysema
 Stroke
 Asthma
When? _____________
 Epilepsy
 Swelling of feet or ankles
 Kidney Disease
 Back Problems
 Excessive thirst/urination
 Thyroid Problems
 Liver Disease
 Bleeding Abnormally
 Fainting
 Tonsillitis
 Mitral Valve Prolapse
 Blood Disease
 Nervous Problems
 Frequent vomiting,
 Tuberculosis
 Blood transfusions
 Tumors
 Pacemaker
nausea
 Blurred vision
 Frequent urination
 Ulcer
 Persistent cough,
 Cancer
 Glaucoma
 Other
 Chemical Dependency
coughing up blood
 Prolonged Bleeding
 Headaches
Describe
 Chemotherapy
 Psychiatric Care
 Heart Murmur
 Circulatory Problems
 Heart Problems
 Radiation Treatment
 Congenital Heart Defect
Describe ____________
TURN FORM OVER AND ANSWER QUESTIONS ON THE BACK
Please do not write below this space
DATE
ASA:
Patient’s Name:
(Last)
Occupation:
(First)
City:
Address:
Home Phone: (
)
Business Phone: (
)
Cell: (
DENTAL AND SOCIAL HISTORY
Your Dentist’s Name:
Address:
How often do you brush?
_____________
)
______
Date of last exam:
City:
Date of last dental X-rays:
__ Zip:
Zip:
______
Phone: (
)
______
Type of survey?: Bitewings Full Mouth X-ray Panographic X-ray
___ How often do you floss?
Have you had problems with prior dental treatment? Yes No
Date of last teeth cleaning:
_____________________
Have you had problems with dental anesthesia? Yes No
Reason for today’s visit :
Please check () any of the following conditions that apply to you:
Grinding teeth
Bad breath
Jaw Pain
Bleeding Gums
Loose teeth or broken
Clicking or popping jaw
fillings
Cold sores
Oral Surgery
Food collection between
Orthodontics
teeth
List any vitamins, minerals or herbal products that you take:
Have you ever taken any of these diet medications? Dexfenfluramine
Do you smoke/chew tobacco products? Yes No What kind?
Do you use recreational drugs? Yes No What kind?
Do you drink alcohol? Yes No
What kind?
Sores or growth in your
mouth
Teeth Extracted
Periodontal/gum surgery
Root canal
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
_______
Fen-phen
Pondimin
Redux
How often?
How often?
How often?
_______
______________
______________
Certification and Assignment
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform the student
hygienist if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian or Personal Respresentative
Date
Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient
In case of emergency notify:
Relationship:
Address:
City:
Zip:
_____________________
Phone: (
)
_______
Please do not write below this space
DATE
Baseline Evaluation
Date
BP
Any contraindications to local anesthetic? Yes No If yes, explain:
Consultation Needed? Yes No
Student:
Pulse
R
Clear for Assignment? Yes No
#
Dentist:
#
Date:
G:\Forms\Form P-01d