New Patient - Health History

THE HYGIENE HOUSE

Cathy olander, RDHAP, BS Lic # HAP 1158. 209-676-9375
HEALTH HISTORY FORM
Patient Name

First NameLast Name
Patient Date of Birth
Contact Number for Patient
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Relationship to you
Emergency contact phone number
Please enter a valid phone number.
Do you currently reside in a facility other than your home for daily living assistance?

YesNoOther
If other, please explain
Name of Facility
Best person to contact
Address of residing facility where dental hygiene services will be performed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility phone number
Please enter a valid phone number.
Welcome to THE HYGIENE HOUSE! Now, let's see what we can help you with.
What is your main concern:
Are you currently experiencing dental pain or discomfort?

YesNo
What is the date of your last dental cleaning and xrays ?(Estimate if needed)

MonthDayYear
Do you remember the Name, city, and state of your previous dentist?
Have you ever had any of the following in the last 3 years? (Check all that apply)

Bad BreathBad Dental ExperienceBleeding when you brush your teethBleeding when you floss your teethBurning sensation on tongueChew on only one side of the mouthClicking, Popping, or Locking of JawDenture or Partial Denture(s)Difficult ExtractionsDry MouthEar AchesFood Collection Between TeethGrinding/Clenching TeethGums Swollen or TenderHeadachesInjury to your Head, Mouth, or TeethJaw Pain or TirednessLoose TeethMouth BreathingNeck PainOrthodontic Treatment (at any time)Periodontal Therapy (aka Deep Cleaning)Pierced TongueReaction to Dental AnestheticSensitivity to ColdSensitivity to HotSensitivity to SweetsSores or Growths in Mouth
Do you have any of the following diseases or problems? If you check any of these items, report your condition to a member of the staff immediately.

Active TuberculosisExposure to TuberuculosisPersistent cough greater than a 3 week durationCough that produces blood
Indicate Height and Weight
Women Only (Check all that apply)

PregnantNursingBirth Control PillsHormone Replacement
How many weeks pregnant?
List the name, specialty, and phone number (if available) of all physician(s) currently caring for you:
Date of Last Health Exam/Physical (Estimate if needed)

MonthDayYear
Are you in good health?

YesNo
If NO, Please provide details here
Has there been any change in your general health in the last year?

YesNo
Please provide details here
Have you had a serious illness, operation, heart conditions or been hospitalized in the past 5 years?

YesNo
Please provide details here
Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?

YesNo
List antibiotics and the physicians name, specialty, and phone number.
Do you use controlled substances (drugs)?

YesNo
If you use tobacco (smoking, snuff, chew, bidis) how interested are you in stopping?

Very InterestedSomewhat InterestedNot Interested
Do you drink alcoholic beverages?

YesNo
How many alcoholic drinks did you drink in the past 24 hours?
How many alcoholic drinks do you typically drink in a week?
Check all medical conditions that apply to you:

Heart MurmurHeart PacemakerHeart attackMitral Valve ProlapseInfective EndocarditisHigh Blood pressureHemophiliaJoint ReplacementStrokeLung DiseaseEpilepsy/SeizuresDiabetes Type IDiabetes Type II
Hepatitis A, B, CParkinson's DiseaseAutismLiver diseaseMultiple SclerosisCerebral PalsyDementiaAlzheimer's DiseaseHIVBlindnessDeafRadiation TherapyAllergies to metalAllergies (seasonal)
Are you allergic to or have you had a reaction to: (Check all that apply)

AspirinClindamycinEpinephrineErythromycinSilverIodineLatexLocal AnestheticsPenicillinSedativeSulfaTetracyclineOther
If you have had joint replacement(s), indicate joint(s), date of surgery, and any complications here:
List any PRESCRIPTION MEDICATIONS you are taking : (Name of Medication, Dosage, Frequency)
List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.
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.
I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires 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 my errors or omissions that I may have made in the completion of this form.
Signature of Patient or Guardian/Custodial

Clear
Name of Patient or Guardian/Custodial

Print First namePrint Last Name
Date

MonthDayYear
Date
Should be Empty:

THE HYGIENE HOUSE

HEALTH HISTORY FORM

Welcome to THE HYGIENE HOUSE! Now, let's see what we can help you with.