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Client:
Medical
CLIENT IDENTIFICATION Alert:
Premedicati
on:
Guardian’s Name_______________________
REGISTRATION INFORMATION
Address:
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© Trillium College
June 2007
Clinic Clinic Form
PERSONAL INFORMATION
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© 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
__ __
5. Have you had any changes in your health in the past year?
__ __
bridges, or implants?_____________________
__ __
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© Trillium College
June 2007
Clinic Clinic Form
10.9. Are any of your teeth sensitive to hot, cold, sweets/ pressure?
__ __
12.If yes, how long have you smoked? ____ How many/ day
__ __
19. Do you have any concerns regarding the health of your gums?
__ __
20.Swelling__ Bleeding__ Sore/sensitive__ Receding__
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© Trillium College
June 2007
Clinic Clinic Form
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© 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?
__ __
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
_______________________________________________________
11. Have you ever had any previous injury to the areas of the head?
__ __
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© Trillium College
June 2007
Clinic Clinic Form
12. Woman Only: Are you pregnant?_____ Due Date: __________What week?__________
14.AIDS/ HIV
__ __
15.Heart Disease
__ __
16.Anemia __ __
17.Angina Pectoris __ __
18.Arthritis __ __
19.Heart Murmur
__ __
20.Joint Replacement __ __
22.Organ Transplant __ __
23.Shortness of Breath __ __
24.Blood Disorders __ __
25.Pacemaker __ __
26.Herpes
__ __
28.Venereal Disease __ __
29.Rheumatic Fever __ __
30.Cancer __ __
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© Trillium College
June 2007
Clinic Clinic Form
32.Diabetes
__ __
33.Swollen Ankles __ __
34.Hep A, B or C __ __
36.Epilepsy __ __
38.Stroke __ __
40.Osteoporosis __ __
41.Tuberculosis __ __
42.Bronchitis __ __
44.Glaucoma __
__
45.Excessive Bleeding
__ __
46.Sinus Problems
__ __
48.Mental Disorder __ __
49.Radiation Treatment __ __
50.Alzheimer’s disease __ __
51.Parkinson’s disease __ __
53.Exposure to SARS __ __
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© Trillium College
June 2007
Clinic Clinic Form
Other: __________________________________________________________
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© 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.
Notes: _________________________________________________________________
_______________________________________________________________________
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© Trillium College
June 2007
Clinic Clinic Form
_______________________________________________________________________
Have you ever had: rheumatic fever, hip, knee or any joint replacement? _____________
Have you been admitted to the hospital or had a physician visit since your last treatment at this
dental clinic? _____________________________________________________
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© Trillium College
June 2007