Pueblo Community College Dental Health Questionnaire
Today’s Date: _______________
Driver’s License #______________________ Exp. (mm/yyyy)___________________
Sex: M _____F______
Patient Name (First & Last) ______________________________________________Birthdate: ______/______/_____ Age: ____
Address ______________________________________________ City_____________________ State_____ Zip___________
Home Phone __________________________ Cell Phone ______________________ Work Phone _______________________
Spouse (if appropriate) or Emergency Contact _______________________________ Phone _____________________________
If patient is a minor child or dependent adult, what is the relationship of the person who brought the child to this clinic?
Parent_____________________ Relative____________________ Legal Guardian________________ Other________________
Name of legal guardian or caretaker: __________________________________________________________________________
Physician Name: ___________________________________________ Physician Phone: _______________________________
Dentist Name: ______________________________ Dentist Phone: __________________ Date of Last Visit________________
Would you object to consultation with your Dentist or Physician, should a need arise?
No
Yes (please comment if yes)
_____________________________________________________________________________________________________
Please explain the symptoms or complaint for which you are now seeking care_________________________________________
_____________________________________________________________________________________________________
A. DENTAL HISTORY
Check any of the following conditions that apply
Have you ever been treated for any of the (four) conditions below?
Sores in your mouth
Periodontal Treatment (gum surgery)
Sensitive teeth
Orthodontics (braces)
Bleeding gums
Endodontics (root canal)
Difficulty chewing
Dental Extractions, Fillings
Pain in the jaw joints
Dry mouth
Dental pain/discomfort
Do you drink bottled or filtered water? If yes, how
often? Circle One: Daily / Weekly / Occasionally
Anxious about receiving dental treatment
Injury to face or jaw
Have you ever had complications during previous dental
treatment?
Yes
No
Have you ever had a reaction to a local dental anesthetic
(injection to numb)?
Yes
No
Do you have any of the following dental habits:
Clenching /
Grinding /
Chewing objects
Do you use any tobacco products?
Do you bleed easily?
Yes
Yes
No
No
Continued on next page
B.
HEALTH HISTORY
Check any of the following past or present conditions that apply:
Congestive Heart Disease
Heart Disease or Attack? Date_______
Angina Pectoris
High Blood Pressure
Congenital Heart Disease (CHD)
Artificial Heart Valve
Heart Pacemaker
Heart Surgery? Date_________
Previous infective endocarditis
Damaged valves in transplanted heart
Unrepaired valves in transplanted heart
Unrepaired, cyanotic, CHD
Repaired CHD with residual defects
Emphysema or Lung Disease
Tuberculosis
Asthma
Diabetes Last A1C #______
Thyroid Disease
Cancer or Tumor
Chemotherapy
X-ray/Cobalt Treatment
Arthritis, Rheumatism
Steroids/Cortisone Medicine
Glaucoma
Back Trouble/Surgery
Kidney Trouble or Disease
HIV+/AIDS
Hepatitis A (infectious) Hep B(serum) Hep C
Liver Disease or Yellow Jaundice
Drug Addiction
STD’s
Epilepsy or Seizures
Psychiatric Treatment
Sickle Cell Disease
Surgery
Stroke
Anemia/Bleeding Disorders
Disability (hearing, vision, etc.)
Other conditions past or present not listed
_____________________________________
Osteoporosis:
Have you been diagnosed with Osteoporosis?
Yes
No
Allergies:
Are you allergic to or have had a reaction to any of the following:
Have you taken, are taking, or scheduled to take
Bisphosphonates? (Aredia, Fosamax, Boniva, Actonel, etc.)
If yes, please list.___________________________________
_________________________________________________
Local anesthetics
Joint Replacement (Artificial Joint):
If yes, date________________ Type __________________
_______________
___________________
Please Circle
Sulfa drugs
Aspirin
Iodine
Penicillin
Latex (rubber)
Amoxicillin
Codeine
Other _____________
FEMALES ONLY:
Are you presently pregnant or trying to become pregnant?
Yes, number of weeks__________
No
Have you had any complications?
Yes
No
If yes, specify_____________________________________
Using birth control drugs? (pills, patches, implants, etc.)
Yes
No
Name of physician__________________________________
Are you nursing?
Yes
No
Please list any disease associated with your family history: __________________________________________________________________
Are you presently under active treatment by a physician? If so, for what and when? _____________________________________________
_________________________________________________________________________________________________________________
Are you presently taking any prescription or recreational drugs? If so, please list the medications and for what condition(s).
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful
health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about
inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any
action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Patient or Guardian__________________________________________________________ Date______________________________________
***********************************************************************************************************
Clinic Use Only
Signature of Student Clinician: ________________________________ Signature of Faculty: ____________________________
Signature of Dentist (Dental Clinic only)_____________________________________________________________________