Clinic Clinic Form

Client:

Medical
CLIENT IDENTIFICATION Alert:

Premedicati
on:

The client is an: Adult___ Child___ Adult under Guardianship___

Guardian’s Name_______________________

REGISTRATION INFORMATION

Name: Dr.__ Mr.__ Mrs.__ Miss__ Ms.__

Address:

Home Phone: ( ) Work Phone: ( )

Cell Phone: ( ) Email:

Emergency Contact: Relationship: Phone ( )

Family Physician: Phone ( )

1
© Trillium College
June 2007
Clinic Clinic Form

PERSONAL INFORMATION

Prefers to be called: Occupation:

Date of Birth: Age: Male: Female:

Marital Status: Name of Spouse:

Who may we thank for referring you?

Reason for today’s dental visit:

Are other family members’ clients at Names:

this clinic? Y__ N__

2
© Trillium College
June 2007
Clinic Clinic Form

Client:

Medical
Alert:

Premedicati
on:
DENTAL HISTORY

Please check Y or N for EACH question. If unsure, please ask for assistance.
Y N

1. When was the last time you had a dental cleaning? ______________________
2. Date of your last X-Rays? ______________ How many _________________
3. Have you ever had any of the following:
i. Periodontal (Gum) Treatment
__ __

ii. Orthodontic Treatment

__ __

iii. Oral Surgery

__ __

4. Do you see a dentist regularly?

__ __

5. Have you had any changes in your health in the past year?
__ __

6. Are there any sores or growth spots in your mouth?

__ __

7. Do your gums bleed when brushing or eating?

__ __

8. Do you have any loose teeth?

__ __

9. Have you had tooth replacements such as dentures, partials,

bridges, or implants?_____________________
__ __

3
© Trillium College
June 2007
Clinic Clinic Form

10.9. Are any of your teeth sensitive to hot, cold, sweets/ pressure?
__ __

11.10. Do you smoke?

__ __

12.If yes, how long have you smoked? ____ How many/ day
__ __

13.Are you interested in taking part in a smoking cessation program?

__ __

14.How often do you brush your teeth? ___________________

15.Do you suffer from bad breath?
__ __
16.Do you floss or use any other at home dental aid?
__ __
17.How often? __________________

18.Have you ever experienced jaw or facial pain such as:

i. Clicking or popping __
__

ii. Pain in the jaw joint, eyes or ears

__ __

iii. Frequent headaches

__ __

iv. Difficulty chewing, opening or closing the mouth

__ __

19. Do you have any concerns regarding the health of your gums?
__ __
20.Swelling__ Bleeding__ Sore/sensitive__ Receding__

21. Do you have any of the following habits?

i. Clenching/ Grinding
__ __

ii. Nail biting __ __

iii. Placing foreign objects in the mouth (pencil, pins etc.)

__ __

22. Have you had a bad dental experience? ___________________

__ __
a. __________________________________________________

4
© Trillium College
June 2007
Clinic Clinic Form

23. Do you get nervous or anxious before going to the dentist?

__ __

5
© Trillium College
June 2007
Clinic Clinic Form

Client:

Medical
Alert:

Premedicati
on:

MEDICAL HISTORY Y N

1. Have you been treated for any medical condition within the last year?
__ __

If yes, explain: ___________________________________________

2. When was your last complete physical examination? _____________

3. Are you currently under the care of a physician? If so, what for?
__ __
_______________________________________________________

4. Have you ever been told to take antibiotics prior to dental treatment?
__ __
5. Have you gained or lost more than 10 lbs. in the past year?
__ __
6. Have you ever taken fen-fen, dexfenfluramine or fenfluramine?
__ __
7. Do you sleep with more than 2 pillows?
__ __
8. Have you ever reacted to any of the following? (please circle)
ANTIBIOTICS (penicillin, sulfa etc.), CODEINE, BARBITUATES

(sleeping pills), ASPIRIN, ANAESTHETIC (freezing), other medication

_______________________________________________________

9. What PRESCRIPTION/NONPRESCRIPTION drugs or HERBAL REMEDIES

Are you currently taking?______________________________________

10. Do you have any of the following? (please circle)

__ __
Asthma, Food Allergies, Metal or Latex Allergies, Rashes or Hives

11. Have you ever had any previous injury to the areas of the head?
__ __
6
© Trillium College
June 2007
Clinic Clinic Form

(Face, mouth, neck, teeth)_________________________________

12. Woman Only: Are you pregnant?_____ Due Date: __________What week?__________

13. Have you ever had or have any of the following?

Y N

14.AIDS/ HIV
__ __
15.Heart Disease
__ __

16.Anemia __ __

17.Angina Pectoris __ __

18.Arthritis __ __

19.Heart Murmur
__ __

20.Joint Replacement __ __

21.Mitral Valve Prolapse __ __

22.Organ Transplant __ __

23.Shortness of Breath __ __

24.Blood Disorders __ __

25.Pacemaker __ __

26.Herpes
__ __

27.Cardiac Bypass Surgery

__ __

28.Venereal Disease __ __

29.Rheumatic Fever __ __

30.Cancer __ __

31.Congenital Heart Disease __ __

7
© Trillium College
June 2007
Clinic Clinic Form

32.Diabetes
__ __

33.Swollen Ankles __ __

34.Hep A, B or C __ __

35.High/ Low Blood Pressure __ __

36.Epilepsy __ __

37.Thyroid Disease/ problem __ __

38.Stroke __ __

39.Kidney/ Liver/ Lung Disease __ __

40.Osteoporosis __ __

41.Tuberculosis __ __

42.Bronchitis __ __

43.Fainting/ Dizzy spells __ __

44.Glaucoma __
__

45.Excessive Bleeding
__ __

46.Sinus Problems
__ __

47.Stomach problems/ Ulcers __ __

48.Mental Disorder __ __

49.Radiation Treatment __ __

50.Alzheimer’s disease __ __

51.Parkinson’s disease __ __

52.Artificial Heart Valve __ __

53.Exposure to SARS __ __

8
© Trillium College
June 2007
Clinic Clinic Form

Other: __________________________________________________________

Blood Pressure , Pulse Reading(s), Respiration _____________________________

9
© Trillium College
June 2007
Clinic Clinic Form

Client:

Medical
Alert:

Premedicati
on:

GENERAL CONSENT

I, the undersigned, verify that I have answered the health questionnaire accurately, to the best
of my knowledge, and have not knowingly omitted any information. I authorize that the dental
clinic of Trillium College can utilize this information as needed. I understand that information
provided from or to my physician may be necessary in order to fully complete the health history.
In the future, should there be any change in the status of my health; I agree that I will notify the
Trillium College Dental Clinic.

Client Signature: _____________________________ Date: _______________________

Student Signature : ________________________________

Instructor Signature: ________________________ Date:__________________________

Permission to Proceed Y__ N__ Signature of DDS: _____________________________

Notes: _________________________________________________________________
_______________________________________________________________________

10
© Trillium College
June 2007
Clinic Clinic Form

HEALTH HISTORY UPDATES

Are there any changes in your Health History? _________________________________

_______________________________________________________________________

Have you ever had: rheumatic fever, hip, knee or any joint replacement? _____________

Have you changed family physicians? ________________________________________

List all medications (prescription or non-prescription) being taken:

1) ______________________ 2) ______________________ 3) ____________________

4) ______________________ 5) ______________________ 6) ____________________

Have you experienced any allergies to drugs, food, metal or latex?

_______________________________________________________________________

BP reading(s), Pulse, Respiration ____________________________________________

Have you been admitted to the hospital or had a physician visit since your last treatment at this
dental clinic? _____________________________________________________

Other Changes: _________________________________________________________

Client Signature: ____________________________ Date: _______________________

Student Signature: _____________________ Reviewed by: ______________________

11
© Trillium College
June 2007