Form 21430-003 -Health History Form - Burlington County

Burlington County College Dental Hygiene Clinic

Adhere medical alert sticker

HealtH History Form

here if applicable.

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email: ______________________________________ today’s Date: _________________

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our

records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be

additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

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Name: _____________________________________________ Home phone:____________________ Business/Cell phone: _______________

LAST

FIRST

MIDDLE INITIAL

Please include area codes with all phone numbers

address: ____________________________________ City: ________________________________ state: _________ ZiP: _____________

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occupation: __________________________________ Height: __________ Weight: _________ Date of Birth: ______________ sex: o M o F

emergency Contact: ____________________________________________________________ relationship: ________________________

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Home phone: ______________________ Cell phone: __________________________

iF you are ComPletiNg tHis Form For aNotHer PersoN, WHat is your relatioNsHiP to tHat PersoN?

Your name: ___________________________________________________________________ Relationship: __________________________

Do you have any of the following diseases or problems?

(Check DK if you don’t know the answer to any of the questions)

yes

No

DK

Active tuberculosis ..................................................................................................................................................................................................................... o

o

o

Persistent cough greater than a 3-week duration ...................................................................................................................................................................... o

o

o

Cough that produces blood ........................................................................................................................................................................................................ o

o

o

Been exposed to anyone with tuberculosis ................................................................................................................................................................................ o

o

o

If you answered yes to any of the 4 items above, please stop and return this form to the receptionist.

DeNtal iNFormatioN – Please mark (X) your responses to the following questions.

yes

No

DK

yes

No

DK

Do your gums bleed when you brush or floss?................................... o

Are you currently experiencing dental pain or discomfort? ............... o

o

o

o

o

Are your teeth sensitive to cold, hot, sweets or pressure? .................. o

Do you have earaches or neck pains? ................................................. o

o

o

o

o

Does food or floss catch between your teeth? ................................... o

Do you have any clicking, popping or discomfort in the jaw? ............ o

o

o

o

o

Is your mouth dry? ............................................................................ o

Do you brux or grind your teeth? ...................................................... o

o

o

o

o

Have you had any periodontal (gum) treatments? ........................... o

Do you have sores or ulcers in your mouth? ....................................... o

o

o

o

o

Have you ever had any orthodontic (braces) treatment? ................... o

Do you wear dentures or partials? ..................................................... o

o

o

o

o

Have you had any problems

Do you participate in active recreational activities? ........................... o

o

o

associated with previous dental treatment? ...................................... o

Have you ever had a serious injury to your head or mouth? .............. o

o

o

o

o

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Is your home water supply fluoridated? ............................................ o

o

o

Date of your last dental exam: ____________________

Do you drink bottled or filtered water? ............................................. o

o

o

What was done? __________________________________________

If yes, how often? Circle one:

DAILY

WEEKLY

OCCASIONALLY

_____________________________________________________

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Date of last dental X-rays: _______________________

What is the reason for your dental visit today? _________________________

_____________________________________________________

Dentist name and contact information: _____________________________

_____________________________________________________

_____________________________________________________

How do you feel about your smile? ________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

meDiCal iNFormatioN – Please mark (X) your responses to indicate if you have or have not had any of the following diseases or problems.

yes

No

DK

yes

No

DK

Are you now in the care of a physician? ..............................................o

Have you had a serious illness, operation

o

o

or been hospitalized in the past five years? ........................................o

o

o

Physician’s name: __________________________________________

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If yes, what was the illness or problem? _____________________________

Phone number: ___________________________________________

Address: _______________________________________________

_____________________________________________________

City/State/ZIP: ____________________________________________

Are you taking or have you recently taken any

prescription or over-the-counter medicine(s)? .................................. o

o

o

Are you in good health? .....................................................................o

o

o

If yes, please list them all, including vitamins natural or herbal

Has there been any change in your general health

preparations, and/or any diet supplements: __________________________

within the past year? .........................................................................o

o

o

_____________________________________________________

If yes, what condition is being treated?

_____________________________________________________

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Date of your last physical exam: ___________________

_____________________________________________________

Please complete both sides of this form.

FORM 21430-003 REV 06/13