ECC Dental Hygiene Patient Health History Form
Instructions to Patient: Please answer the following questions as completely and accurately as possible. All
information is CONFIDENTIAL.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Patient name: _______________________________________________ Birthdate: _____________________
Address: ________________________________________ City: ___________________ Zip Code__________
Occupation: ____________________ Ethnicity: _____________________ Phone: (____) _________________
Physician’s name: ___________________________________ Physician’s phone: (____) _________________
Dentist's name:
___________________________________ Dentist's phone (____)____________________
If you are completing this form for another person, what is your relationship to that person? ________________
Referred by: ___________________________________________________
Day of last physical exam: _______________________ Date of last dental exam: ______________________
Are you in good health? _______________________________________________________ YES
NO
Are you now under the care of a physician_________________________________________ YES
NO
If YES, what is the condition being treated? _________________________________________________
Have you had any serious illness, operation, or been hospitalized in the past 5 years?_______ YES
NO
If YES, what was the illness or problem? ____________________________________________________
Are you allergic or had any reactions to any medicines, drugs, local anesthetics, or other
substances? _____________________________________________________________
YES
NO
If YES, what was the allergy or reaction? ____________________________________________________
15. Medical Information: Circle the diseases, conditions, and/or treatments that you have now or have had in the
past?
AIDS/HIV
Allergies
Anemia
Angina/Chest pain
Aniexty
Artificial joint
Arthritis
Asthma
Cancer
Cardiovascular
disease
Chemotherapy
Bisphosphonate tx
(i.e. Boniva/Fosamax)
Chronic cough
Diabetes
Eating disorder
(Bulemia/Anorexia)
Gastric reflux
Emphysema
Epilepsy/seizures
Congenital heart
disease (present
since birth)
Fainting/dizziness
Glaucoma
Heart Disease
Heart murmur
Hepatitis/jaundice/liv
er disease
Kidney/renal disease
Hiatal hernia
High/low blood
pressure
Mytral valve prolapse
Indwelling vein
catheter
Fever blisters/cold
sores/herpes
Heart pacemaker
Infective
endocarditis
Osteonecrosis of
the jaw
Respiratory
Pain in jaw joints
Mental/emotional
impairment
Physical impairment
(i.e. vision, hearing,
speech)
Stroke/TIA
Prosthetic implant
Bleeding disorder
Organ transplant
Other:
STD/VD (i.e.
Swollen glands
syphilis)
Tuberculosis Unexplained weight
Ulcers
Yellow jaundice
active
gain/loss
Address all circled or YES responses in this space.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
16 . Dental Information
A. How long has it been since you have seen a dentist? 6 ms - 1 yr 1 - 3 yrs 4-6 yrs over 7 yrs
B. How long has it been since you had your teeth cleaned? 6 ms - 1 yr 1 - 3 yrs 4-6 yrs over 7 yrs
C. Circle the dental diseases, conditions, and/or treatments that you have now or have had in the past?
Family history of
dental decay
Periodontal (gum)
disease
Orthodontics
(braces)
Oral Surgery
Dental Implants
Family history of
loss of teeth or the
use of dentures
Dentures or partials
Difficulty chewing
Loose teeth
Catch food between
your teeth
Mouth odors or bad
breath
Dry mouth
Clicking or popping
when you open your
mouth
Sore or bleeding
gums
Tooth sensitivity to
hot, cold, pressure or
sweets
Clench or grind your
teeth or have jaw
pain
Comments:
D. Do you expect to keep your teeth all of your life? ________________________________ YES
NO
E. Do you chew or suck on hard candy, cough drops or mints or chew gum? ____________ YES
NO
F. What types of beverages to you typically drink between meals? ______________________________
_________________________________________________________________________________
G. What are the sources of your drinking water? (Circle all that apply)
Bottled Water
Well Water
City Fluoridated Water
Other _________________
H. How often do you brush? ___________________________ _______________________
I. How often do you floss? ___________________________________________________
J. Are you nervous about dental work or have you had a bad experience with dental work?_YES
NO
If Yes, please explain: _______________________________________________________________
17. Tobacco Use:
A. Are you a tobacco user? If no, go to question #18. ______________________________ YES
NO
B. Type: ______________________ Amount: _________________ Number of Years: __________
C. Are you interested in quitting tobacco?________________________________________ YES NO
18. Do you use alcoholic products?_________________________________________________ YES NO
19. Women: Are you pregnant or think you might be pregnant? __________________________ YES NO
20. What is your chief dental complaint? ______________________________________________________
Current Medications Use the back of the page if more space is needed.
Medication
Dosage
Frequency
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth
above have been answered to my satisfaction. I will not hold the dentist, dental hygiene faculty, or any member of the
staff responsible for any errors or omissions that I may have made in the completion of this form.
BP: _______________Pulse: _______________ Respiration: _______________Temperature: ______________
Signature of the Patient: _____________________________________________ Date: _____________________
Student Signature:
_____________________________________________ FI: _______________________
El Centro College Dental Hygiene Program
Clinic Information
You have been screened and classified for treatment in the Dental Hygiene Clinic by a dental
hygiene student. The following information will be helpful in planning your time and costs for
treatment.
Treatment in the Dental Hygiene Clinic requires:
1. Each dental hygiene appointment will typically last an entire clinic session. Therefore plan
that each appointment will be three to four hours in duration.
2. Several appointments are needed to complete your dental hygiene treatment. Three to five
appointments may be required due to the teaching that will occur and supervision
requirements.
3. Please make a note of the student’s name so that you may contact him/her or leave a message.
You may leave a message at the clinic number.
5. Prompt attendance for all appointments is required. Constant tardiness and/or two absences
may result in DISCONTINUED TREATMENT. If you need to cancel, please give your
student at least 24 hours’ notice at the clinic number. If you are more than 20 minutes past
your appointment time, your appointment may be cancelled and another patient scheduled in
your place.
6. No children should attend appointments unless they are receiving treatment. Children who are
receiving treatment MUST be accompanied by a parent or legal guardian. The parent/legal
guardian must remain in the reception area throughout the minor’s appointment session.
7. Your health is our primary concern. Please understand that a medical consultation may be
required PRIOR to starting dental hygiene treatment. If a medical consultation is necessary,
further documentation of your particular medical condition will be required from your
physician.
8. The Dental Hygiene Clinic is not equipped to provide all of your possible dental needs since
our focus is on dental hygiene services. If it is determined that you have other dental needs
you will be advised and provided with a referral. A list of services provided by the dental
hygiene clinic and their fees are on the last page.
9. The temperature of the Dental Hygiene Clinic varies, please dress accordingly and bring a
blanket, if you would like.
10. This is a learning institution. Students are here to receive training and advance their dental
hygiene skills. It is important that you, the patient, acknowledge that your treatment is being
provided by supervised students. As such, you accept any possible inconvenience due to
extended or additional appointments for prescribed treatment.
11. As a learning institution patient case information and photographs may be used for teaching
purposes, however, all care will be taken to remove identifying personal information.
12. Your time and commitment to the student's learning is greatly appreciated. Gifts are not
allowed to be received by students.
Please know that your contribution to our student’s education is invaluable, and we appreciate
your interest and continued support. THANK YOU!
Patient received this form on ____________.
Patient's or Guardian's Signature ___________________________________________________
Faculty or Clinical Administrative Assistant's Signature
______________________________________________________________________________
Summary of Policy on Bloodborne and Infectious Diseases



Due to the nature of the activities performed in the clinic, patients are subject to a work
environment that has the potential of exposure to bloodborne pathogens. The ECC
Dental Hygiene Program has established policies and procedures to ensure an
environment that is safe, and has provided specific bloodborne pathogen training for all
ECC Dental Hygiene students, faculty, and staff.
If a dental hygiene student, faculty supervisor, or patient is exposed to body fluids in a
manner that may transmit bloodborne or infectious disease, both the health care provider
and the patient should be tested for the disease. The cost for treatment rests with the
patient and the student.
The ECC Dental Hygiene Bloodborne and Infectious Disease Policy in its entirely is
available by request to the Clinical Administrative Assistant.
You may view the full Dental Hygiene Program Policies on Bloodborne and Infectious
Diseases upon request. These polices are available from the Dental Hygiene Clinic
Administrator’s Office. Dental Hygiene faculty will discuss or answer any question an applicant
or patient may have concerning these policies.
El Centro College Dental Hygiene
Clinic Patient Bill Of Rights
The students, faculty and staff of El Centro College strive to provide each patient with a high
quality of care in the Dental Hygiene Clinic. As our patient, you are entitled to:
1. Considerate, respectful and confidential care;
2. Treatment that meets the Standard of Care in the dental hygiene profession;
3. Continuity and completion of treatment;
4. The right to ask questions about your dental health or treatment at any time;
5. Access to complete and current information about your dental health;
6. Adequate information on your needs to give informed consent to proposed treatment;
7. Accurate information about the costs prior to treatment;
8. Explanation of recommended treatment, treatment alternatives, the option to refuse treatment,
the risk of no treatment, and expected outcomes of treatment options;
9. Confidentiality regarding your medical history, oral health and your dental records; and
10. The right to review the records pertaining to his/her dental care, have the information
explained or interpreted as necessary, except when restricted by law, and receive a copy of
relevant patient's chart information for a nominal fee.
.
_______________________________________________
Patient (or Parent of a minor child) Signature
______________________________________________
Faculty or Clinical Administrative Assistant's Signature
______________________
Date
______________________
Date
NOTICE OF PRIVACY PRACTICES OF EL CENTRO COLLEGE DENTAL HYGIENE
PROGRAM
_________________________________________________________
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
________________________________________________________
El Centro College (ECC) is required by law to protect the privacy of your health
information and to provide you patients/guardians with notice of its legal duties and Privacy
practices with respect to protected health information. ECC is required by the privacy regulation
issued under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to
maintain the privacy of your Protected Health Information and to provide you with notice of its
legal duties and privacy practices with respect to your Protected Health Information. This
document is notice to you of ECC’s privacy practices.
Disclosures That Can Be Made Without Your Authorization
1. Since this program is a training program to educate future dental hygienists, your
information may be used as educational material to benefit other students who have not
directly participated in your care. If your protected health information is used, all
reasonable efforts will be made to conceal your identity, including photographs.
2. The program may at times find it necessary to release all or portions of your protected
health information to other healthcare workers without the patient's/guardians written
authorization. Examples of this release of information would include referrals to dentists
for work to be performed, submission of copies of x-rays made in our facility, physicians'
requests, insurance or third-party payer requests, or when required by law or enforcement
officials.
3. The program may disclose protected health information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or
other crime in order to avert a serious threat to your health or safety or the health or
safety of others.
4. To a health oversight agency for oversight activities authorized by law, including audits;
civil, administrative or criminal investigations; inspections; licensure or disciplinary
actions; or other activities necessary for appropriate oversight of the health care system,
government benefit programs for which health information is relevant to beneficiary
eligibility, entities subject to government regulatory programs for which health
information is necessary for determining compliance.
5. To provide appointment reminders, information about treatment alternatives or other
health-related benefits and services that may be of interest to you by (telephone, mail,
and/or email).
6. In the event of an emergency, the program may disclose pertinent information to
responding healthcare personnel. The program will use its professional judgment
disclosing only health information that is directly relevant to your care.
Your records and the Protected Health Information contained therein are the physical
property of ECC.
Your Privacy Rights Regarding Protected Health Information:
1. Copies of records and/or radiographs will be released to the patient themselves or the
legal guardian of record after signing a release form. Copies of relevant records will be
released on a one-time basis.
2. The right to receive a copy of this Notice of Privacy Practices upon request. The law
requires ECC to ask you to acknowledge receipt of your copy.
ECC will not disclose your Protected Health Information except as described in this
Notice without your written authorization. Your written authorization may be revoked by you in
writing at any time by sending a written notice of revocation to the person listed at the end of this
Notice.
EL CENTRO COLLEGE DISTRICT RESERVES THE RIGHT TO CHANGE ITS
PRIVACY PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR
ALL PROTECTED HEALTH INFORMATION IT MAINTAINS.
This Notice is effect as of September 15, 2016.
If you have any questions or want to make a written request pursuant to the rights described
above, please contact: Dr. Sheila Vandenbush, HIPAA Privacy Officer @
[email protected]. .
a. If you believe your privacy rights have been violated, you may file a complaint with the
HIPAA Privacy Officer and with The Texas Attorney General.
b. The Texas Attorney General has a website that explains an individual’s privacy rights
under federal and Texas laws. https://texasattorneygeneral.gov/cpd/state-and-federalhealth-privacy-laws
c. ECC will not intimidate or retaliate against any person who files a complaint about the
treatment of his or her Protected Health Information.
PLEASE VERIFY THAT YOU HAVE RECEIVED A COPY OF THIS NOTICE OF
PRIVACY PRACTICES BY SIGNING THE ATTACHED ACKNOWLEDGMENT AND .
AUTHORIZATION FOR RELEASE OF DENTAL INFORMATION.
I, _______________________________________________, authorize release of my dental
Printed Name
records to my dental provider upon my personal request. The Clinical Administrative Assistant
will make all attempts to verify my identity at the time of the request.
____________________________________________________
Signature
__________________
Date
ECC DENTAL HYGIENE PROGRAM SCREENING SHEET (CLINIC USE ONLY)
Date of Screening: _______________
Screener: ______________________
Degree of Difficulty: (Circle)
Faculty Review: ________________
PRE-MEDICATION REQUIRED: YES NO
MEDICAL RELEASE REQUIRED: YES NO
DOD: I
PERIO: 1
Blood Pressure: ______/______
Blood Pressure 2nd Time: ______/______
Patient’s Name: ____________________________________ DOB:
/
/
II
2
III
3
IV
4
Temperature: __________
Pulse:
__________
Patient ID # __________
Home Number: ___________________________________ Cell Number: __________________________________________
Patient Referred By: _________________________ Assigned to Student Hygienist: ________________________
Date/Dates Patient Scheduled: ____________________________________________________________________
For Patients Unable to be appointed at this Time:
I have been advised that I have dental needs that are beyond the capabilities of the dental hygiene students at this time, and that I have been
informed and encouraged to seek professional dental care.
At this time I understand I am not a teaching case. I have been informed and encouraged to continue seeking dental care. If an appointment
becomes available I may be notified and be seen by a dental hygiene student.
_______________________________________________________ __________________________
Patient Signature (Parent/Guardian) or Personal Representative
Date
FRONT OFFICE NOTES:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
FACULTY NOTES:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
NOTES:
Radiographs requested on (Date) _________________________ by _____________________________
Dental office contacted: _________________________________________________________________
Radiographs expected by (date) __________________________________________________________
Comments: ___________________________________________________________________________
______________________________________________________________________________________
Medical consult written on (Date) _________________________ by ____________________________
Condition: ____________________________________________________________________________
Physician contacted: ___________________________________________________________________
Consult reply expected by (date) _________________________________________________________
Comments: ___________________________________________________________________________
Contact Date: Contact Time: Front Office Staff Name:
__________
__________
__________
Outcome (Scheduled, left message,
phone disconnected, etc):
____________ ____________________________ _____________________________________
____________ ____________________________ _____________________________________
____________ ____________________________ _____________________________________