Patient History Form Word of Mouth Dental Hygiene - Patient History Form Step 1 of 3 0% Personal InformationName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Cell Phone NumberEmail Address Preferred Method of Contact Call Text Email Emergency Contact Person Emergency Contact Telephone NumberName of Insurance Company Name of Policy Holder Policy Holder Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Group Policy Number Certificate/Identification Number How did you hear about us? Medical HistoryPhysician’s Name and Location (include phone number if possible) Please check any conditions listed below that you have or have had in the past Allergies Anemia Anorexia Anxiety Arthritis Asthma Bleeding Disorders Bulimia Cancer Chemotherapy Depression Diabetes Dizziness Drug/Alcohol Dependency Emphysema Epilepsy/Seizures Fainting Heart Problems Hepatitis A, B or C High Blood Pressure Immunity Disorder Joint Replacement Lung Disease Radiation Therapy Shortness of Breath Sinus Problems Skin Disorders Stroke Thyroid Disorder Other Please list any current medications below: Dental HistoryName and location of current dentist When was your last dental visit? How often do you usually have a dental check-up? How often do you usually have a dental cleaning? How often do you brush? How often do you floss? Do you prefer to use an electric or a manual toothbrush? Do you like to use anything else when cleaning your mouth? Are you allergic to latex? Yes No Do you smoke cigarettes, cigars, marijuana? Yes No Are your teeth sensitive? Yes No Do you clench or grind your teeth? Yes No Do your gums bleed/hurt? Yes No Do you play sports? Yes No Do you have problems with your jaw? Yes No Do you have a bad taste/odor in your mouth? Yes No Are you nervous of dental treatment? Yes No Have you ever had an unusual reaction to products used during a dental procedure? Are you happy with the look and feel of your teeth? If not, please describe Word of Mouth is a great service providing screening for cavities, gum disease and other oral conditions. Treatments include thorough/gentle cleaning, whitening, desensitizing, fluoride treatments, and fabrication of sports mouthguards. We encourage you to also maintain regular visits with a licensed dentist at least once a year to assess and treat conditions beyond our scope of practice. If you do not have a regular dentist, we are happy to provide a referral to someone great!PHIA (Personal Health Information Act) permits healthcare providers to collect and use your personal health information in order to make informed and sound decisions in providing your healthcare, sharing information with other providers involved in your care, collecting payment for your care including through private insurers if you wish, participating in planning and research, and reporting to governing bodies as required by law.SignatureDateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged.
