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: ___________________________________________________________
(LAST)
(FIRST)
M / F BIRTHDATE: ____________
(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
Y N
Y N
Y N
Y N
Y N
1. Are you allergic to Latex? ___________________________________________
2. Have you been hospitalized in the last two (2) years? If so, why? ____________________________________
3. Have you been under a physician’s care (i.e., annual physicals, emergency care) during the last two (2) years?
___________________________________________________
4. Do you have ANY known drug, medication, or material allergy?
Please list: _________________________________________________________
5. Have you ever had excessive bleeding requiring special treatment or are you on blood thinners?
_____________________________________________
6. Do you use tobacco in any form? (circle) cigar, pipe, cigarette, chew.
7. Has your physician ever said you have cancer or a tumor? If so, when & what kind? ____________________
8. WOMEN: Are you pregnant? If so, what trimester? ______________________________________________
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
9. Circle any of the following conditions that apply to you:
A. Unstable Angina
B. Active Hepatitis: Type ______
C. Active Tuberculosis
D. Heart Attack or Stroke within 6 months
E. Hemodialysis or Hemophilia
F. Herpetic lesions with tissue not intact
G. Uncontrolled Epilepsy
N
N
N
N
N
N
N
N
N
N
N
N
10. Circle any of the following dental problems and treatments you have had or currently have:
A. AIDS, to include a statement of the T-cell count
B. Corticosteroid/Immunosuppressive Therapy
C. Hepatitis Carrier: Type ______
D. Prosthetic Heart Valve
E. Complex Cyanotic Congenital Heart Disease
F. Surgically Constricted systemic Pulmonary Shunts or Conduits
G. Mitral Valve Prolapse
H. Weight Bearing Joint or Hip Replacement
I. Renal Transplant
J. Vital Signs beyond Normal Limits without Indicated Medical Condition or Medical Clearance
K. Radiation Therapy within 6 Months
L. Ever Taken Phen Fen
Y N
Y N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
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
Y
Y
Y
Y
Y
N
N
N
N
N
N
15. Do you have any dental concerns at this time? If so, explain. ______________________________________
16. Are you nervous about receiving dental care? If so, explain. _______________________________________
17. Have you have a bad dental experience? If so, explain. ___________________________________________
18. Do you eat or drink sweets between meals?
19. Do hot, cold or sweet beverages or food cause discomfort?
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: __________________________