Health History Questionnaire

Welcome to The Polished Tooth Dental Hygiene Center Date: _________________ Patient Information To assist the dental hygienist and ensure your well-being during treatment in our office, please answer the following questions in detail. Thank you

Please print clearly

Name:_____________________________________________________________ Date of Birth: ____/____/____ (First)

(Initial)

(Last)

Address: _____________________________________________________________________________________________________ (Number)

(Apt)

(Street)

(Town)

(Prov.)

Home Tel: (_____) _______________ Cell: (____)______________ Work: (____)_______________

(Postal Code)

Age: _____

M

F

Emergency Contact:__________________________________________ Tel: (____)________________ Family Doctor:____________________________ Tel: (____)_________________ Dentist:___________________________________ Tel: (____)_________________ How did you hear about our office? _____________________________ Referred by:_______________________________

Financial Information

Method of Payment Cash MasterCard Visa Debit Employer:___________________ Insurance Company:_______________________ Policy/Group number:_________________

Medical Information (This information will remain strictly confidential)

YES NO

Are you/ have you been treated for any medical condition within the past year? If so, why? _________________________________________________________________________________________ When was your last medical checkup or visit? ___________________ Has there been any change in your general health in the past year? If yes, please explain. _______________________________________________________________________________ Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list. ___________________________________________________________________________________ ____________________________________________________________________________________________________ Do you have any allergies? If you answered yes, please list using the categories below: Medications ____________________________________________________________________________________ Latex/rubber products _________________________________________________________________________ Other (e.g. hay fever, foods, skin) _______________________________________________________________ Do you have or have you ever had asthma, breathing or lung problems?______________________________ Do you have or have you ever had any heart or blood pressure problems?_____________________________ Do you have or have you ever had a stroke or TIA (ministroke)? ______________________________________ Do you have a prosthetic or artificial joint? __________________________________________________________ Do you have any conditions or therapies that could affect your immune system? e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?__________________________________ Have you ever had hepatitis, jaundice or liver disease? _______________________________________________ Do you have a bleeding problem or bleeding disorder? ________________________________________________ Do you smoke? If yes, how many per day? ______ Years smoked ____________ Past smoker? How many years ago did you quit? ________________

For Women only Are you pregnant? Are you using birth control? ___________________________

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Do you have or have you ever had any of the following? A.I.D.S.

Diabetes

Anemia Angina Pectoris Anorexia nervosa Artificial Heart valve Arthritis/ Rheumatism Artificial Joints Asthma/ Bronchitis Blood disorders Bulimia Cancer Circulation problems Congenital heart lesions Cortisone/steroid

Please check all that apply: H.I.V. Positive

Drug/alcohol dependence Emphysema Epilepsy Glandular disorders Glaucoma Head/neck injuries Heart disease/attack Heart murmur Heart pacemaker/surgery Heart rhythm disorder Hepatitis A B C Herpes High/Low blood pressure

Hodgkin’s Disease Hyper/Hypoglycemia Hypertension Jaundice Kidney disease Liver disease Leukemia Lung disease Malignant hypothermia

Radiation/chemotherapy Rheumatic/Scarlet Fever Sickle Cell Anemia Sinus trouble Stomach problems Stroke Thyroid disease TIA (mini stroke) Tuberculosis Ulcers

Mental/nervous disorder Mitral Valve Prolapse Organ transplant/implant Psychiatric disorder

Venereal disease Other______________ Other______________ NONE

Dental Information Date of last dental/dental hygiene visit _____________________________________________________ What care did you receive at the last dental visit? Dental exam Cleaning Fillings Emergency visit How often do you receive dental treatment or dental hygiene care?___________________________ Have you had radiographs (dental x-rays) in the past two years?Type:______________________ � Yes � No Have you had any dental problems in the last year with your teeth, gums, jaws, chewing? � Yes � No Sensitive Teeth Mouth sores Jaw Problems Loose teeth Dry mouth Toothache Grinding of teeth

Bleeding gums Calculus/ Tartar build-up Broken teeth/fillings Bad breath Cold sores Sore gums Accident/ injury to teeth

Recession Abscess Yellowing of teeth Swelling Sinus Problems Difficulty swallowing Sore jaw

_____________________________________________________________________________ In order that we may be sensitive to your needs, please tell us of any unpleasant experiences you may have had related to oral care. _______________________________________________________ Do you have or have you experienced any of the following?

Are your teeth sensitive to: Cold Sweets Hot Other___________________ Do your gums bleed when you: Floss Brush Never Please rate how happy you are with your smile ( 1- very unhappy 10- very happy) 1 2 3 4 5 6 7 8 9 10 Do you grind or clench your teeth? Are you a mouth breather?

� Yes � No � Yes � No

General Release/Client Consent I, the undersigned understand that the information contained in the medical and dental history is important to treatment. I have completed this form to the best of my knowledge and have not knowingly omitted any data. I consent to the release of medical information from my medical doctor or other health care provider as required

to Josee Laferriere of The Polished Tooth Dental Hygiene Center of Alexandria ON. I authorize this dental hygienist to perform assessment procedures as may be required to determine necessary treatment. I understand that I am responsible to pay for fees associated with my dental hygiene treatment. Policy: I understand that 24 hours notice is required for any cancellation. Evening and Weekend appointments are prime appointments and frequent cancellations may remove my eligibility to these appointment times Client Signature

Self

Parent/Guardian _________________________________ Date: _______________________

Dental Hygienist’s Signature _________________________________________________ Date: _______________________