Registered Dental Assistant Programs in Encino & Anaheim

Pit & Fissure Sealant Patient Forms

Patient Medical Health History

Patient’s First Name

Patient’s Last Name

Date Of Birth

Your Physician’s Name

Your Physician’s Address:

Briefly describe your general health

Directions: Read each question and individually mark YES or NO to the following:

Measles

Yes

Have you been examined by a physician in the last year?

Yes

Has there been any change in your health in the last year?

Yes

Have you ever had surgery? (An operation)

Yes

Please describe

Have you gained or lost much weight recently?

Yes

Have you ever been treated for ear or eye trouble, other than corrective glasses?

Yes

Do you bleed for a long time when you cut yourself?

Yes

Have you ever had hives or a skin rash?

Yes

Have you ever been told you have heart trouble?

Yes

Do you get out of breath easily?

Yes

Do you have spells of dizziness?

Yes

Do your ankles ever become badly swollen?

Yes

Do you have high blood pressure?

Yes

Have you ever been told that you have a heart murmur?

Yes

Do you have any blood disorders?

Yes

Do you have asthma, hay fever, sinusitis or frequent sore throat?

Yes

Have you ever had tuberculosis, emphysema or other lung disease?

Yes

Do you have stomach trouble, frequent diarrhea or constipation?

Yes

Have you ever been told you have kidney or bladder trouble?

Yes

Have you ever had syphilis or gonorrhea?

Yes

Do you ever have fits, convulsions or seizures?

Yes

Do you have arthritis or joint trouble?

Yes

Are your joints often painfully swollen?

Yes

Have you had a general or local anesthetic?

Yes

Have you often had toothaches?

Yes

Do your gums bleed when you brush your teeth?

Yes

Do your gums itch when you brush your teeth?

Yes

Does it hurt when you chew?

Yes

Do you have any problems with your jaws?

Yes

Do you clench or grind your teeth?

Yes

Have you ever had an injury to your face, neck or jaw?

Yes

Do you suffer from frequent or severe headaches, neck or back pain?

Yes

Have you ever received x-ray or radiation therapy to the head or neck?

Yes

Do you have ear pain or pain in front of your ears?

Yes

Does your jaw feel tired after a big meal?

Yes

Must you chew on one side exclusively?

Yes

Is your sleep disturbed by pain in the head and neck region?

Yes

Are your daily activities or routines disturbed by pain in the head and neck region?

Yes

Do you consider yourself a nervous person?

Yes

Do you feel unhappy or depressed?

Yes

Are you easily upset?

Yes

Are you sensitive or allergic to any medicine?

Yes

Are you sensitive or allergic to any of the following?

Penicillin

Yes

Novocaine

Yes

Aspirin

Yes

Iodine

Yes

Codeine

Yes

Sleeping Pills

Yes

Other

Do you smoke or use tobacco?

Yes

Do you drink alcohol daily?

Yes

WOMEN — Are you pregnant?

Yes

WOMEN – Are you in or have passed through menopause (change of life)?

Yes

When did you last have radiographs of your teeth (Full Mouth X-rays — 18-20 images) taken? (Month/Year)

List all Prescription and Non-Prescription Drugs Taken or Used in the Past 3 Months:

List all Hospitalizations for Any Reason:

Patient’s Profile

Address, including: City, State & Zip

Patient’s Phone Number

Physician’s name

Physician’s Address

Physician’s Phone Number

Dentist’s Name

Dentist’s Address

Dentist’s Phone Number

The medical health history above has been reviewed and approved.

Medical Health Statement

I, the patient hereby declare that to the best of m knowledge and belief, I do not have or have not had in the past any systemic condition that can affect the pit and fissure sealant procedure. The disclosures of any of these conditions have been included in my medical health history. These systemic conditions include but are not limited to: heart and/or kidney disease, herpes simplex, hepatitis, diabetes, epilepsy, positive HIV/AIDS, organic heart murmur, and heart valve replacement. Disclosures of these conditions have been forthcoming on my signed and dated medical health history.

I also acknowledge that Fullerton Dental Assistant School or any participant in the pit and fissure sealant certification course will maintain and keep all course related documents confidential.

Patient Release Form

I, the patient, hereby give my permission for a pit and fissure sealant to be performed on me as part of clinical requirement for pit and fissure sealant certification course.

I understand that no charge will be made for the service performed. In consideration thereof, I

hereby agree to waive, release, hold harmless, defend and indemnify, as against any and all

claims I or heirs may have nor or in the future against its principles and/or agents, arising out of

or resulting from my voluntary participation as a patient in the dental trainee program for pit and fissure sealant course.

I have read and I understand the terms of this agreement.

Pit & Fissure Sealant Criteria Form

The patient named above has been examined by the faculty member and meets the following criteria:

Patient must be 18 years of age or older.
Patient must be in good health. (Medical Health History Form will be completed prior to treatment and approved by instructor)
Each patient will have a minimum of four (4) virgin, non-restored, natural teeth, sufficiently erupted so that a dry field can be maintained. In addition, each patient will have a minimum of one (1) tooth in all four quadrants.
Patients with another 4 qualifying teeth (1 tooth per quadrant) can serve as an additional patient.
Third molars (#1,16,17, and 32) cannot be sealed.

I the student, confirm that all the procedures are performed correctly.

Call Us: 714-882-5518

Form - Pit & Fissure Sealant Patient Forms

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