Patient History Form Word of Mouth Dental Hygiene - Patient History Form Step 1 of 3 0% Personal InformationName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationAddress 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 ContactCallTextEmailEmergency Contact PersonEmergency Contact Telephone NumberName of Insurance CompanyName of Policy HolderPolicy Holder Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Group Policy NumberCertificate/Identification NumberHow 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 dentistWhen 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?YesNoDo you smoke cigarettes, cigars, marijuana?YesNoAre your teeth sensitive?YesNoDo you clench or grind your teeth?YesNoDo your gums bleed/hurt?YesNoDo you play sports?YesNoDo you have problems with your jaw?YesNoDo you have a bad taste/odor in your mouth?YesNoAre you nervous of dental treatment?YesNoHave 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 describeWord 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.SignatureDateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameThis field is for validation purposes and should be left unchanged.