Medical/Dental History Form
Patient's Name______________________________Date of Birth_______________________
Home Address ____________________________City_________________________________
Postal Code_____________Phone number_________________ Email___________________
Emergency Contact (name and phone number)_____________________________________
Dental Insurance Information
Name of Primary Insurance Company____________________________________________
Policy holder's name and date of birth____________________________________________
Policy/Plan#________________________ Division/Sect#____________________________
Name of Secondary Insurance Company_________________________________________
Policy holder's name and date of birth___________________________________________
Policy/Plan #_______________________ Division/Sect#_____________________________
Do you have any allergies? If yes, please list______________________________________
Do you take any prescription medications? If yes, please list________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever had any organ transplants, artificial joints or heart surgery? If yes, please list___________________________________________________________________________
Do you have any of the following? Please circle which ones apply to you;
Heart Murmur/Vitral Valve Prolapse       Joint Replacement    Nervous/Mental Disorder       High Blood Pressure    Low Blood Pressure    Hyper/Hypo Glycemia   Epilepsy or Seizures  Cortisone/Steroid therapy   Drug/Alcohol Dependency   Lung Disease    Thyroid Disease   Arthritis   Cancer/Chemotherapy/Radiation   Liver Disease   Heart Attack   Cold Sores   Jaundice   Diabetes   Hepatitis A,B,C   Stroke   Emphysema   Others__________________
Do you smoke/vape? If yes, please list__________________________________________
Are you presently having any dental pain or issues?_______________________________
How frequently were you seeing a dentist/hygienist in the past? ___________________
Name of previous dental office you went to?____________________________________
List number of times per day that you brush your teeth____________________________
List number of times per week that you floss your teeth___________________________
Do you use a manual or electric toothbrush?_____________________________________
Does your jaw pop or click when you open your mouth?       Yes          No
Do you clench or grind your teeth?        Yes           No
Office Policy-Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we will require 48 hours notice otherwise it may be necessary to charge for lost time
Patient Release-I, the undersigned, certify that I provided an accurate and complete personal and medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical/dental history.  I understand that responsibility for payment for the dental hygiene services provided for myself and my dependants is mine and I wll assume respnsibility for fees associated with these services including fees and deductibles above what my dental insurance plan covers.

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Signature                                                                                           Date

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Jana Mossip RDH