Medical Alert: Welcome to Aspect Hygiene

Client Information Form

Your co-operation in completing this intake form is essential to providing you with the highest standard of dental hygiene care. Please answer the following as accurately as possible, as all information is strictly confidential and will remain with the office. If you have any questions or need clarification, please ask your treating hygienist or receptionist who is available to assist you with the completion of this form.

Personal History

First Name:	Last Name:	Preferred Name:
Address:	City:	Postal Code:
Date of Birth: Sex at Birth: Gender Identification:	Health Card Number: Pharmacy: Telephone:	Emergency Contact: Name: Relation: Contact:
Contact: Telephone Cell: Home: Work: Email Preferred method of contact: ☐Text/SMS ☐Telephone ☐Email (Check all that apply) Preferred time of day for contact: ☐AM ☐PM ☐Other: Please specify
Occupation:	Employer:
Family Physician Name: Telephone: Address:	Specialized Physician ☐ Name: Telephone: Address:

Insurance:

Primary Policy Holder Name:	Policy Holder Date of Birth:	Policy Holder Employer:	Policy Holder’s Relationship to Client:
Insurance Company:	Insurance Telephone:	Dependant Code:	Carrier Number:
Policy/Group Number:	ID/Certificate Number:
Secondary Policy Holder Name:	Policy Holder Date of Birth:	Policy Holder Employer:	Policy Holder’s Relationship to Client:
Insurance Company:	Insurance Telephone:	Dependant Code:	Carrier Number:
Policy/Group Number:	ID/Certificate Number:

I the Policy Holder, give authorization to Aspect Hygiene to complete any necessary insurance claim forms on my behalf. I hereby authorize the release of any medical or other information which may be required to process my or my dependants’ dental claims with my insurance company. By signing this section below, I agree to the processing of my and my dependants’ dental claims by Aspect Hygiene by either electronic or manual submission to my insurance company.

Name of Policy Holder(s): Name of Client:

Signature: Date:

Signature: Date:

Direct Payment Authorization

I the Policy Holder, hereby authorize the release of information contained in claims to be submitted electronically or manually to my insuring company and authorize direct payment to Aspect Hygiene for benefits received. I am Solely responsible for any portion not paid by my insurance company and will be accountable for any balance to be paid immediately.

Signature: Date:Click or tap to enter a date.

How did you hear about Aspect Hygiene?

Referral Source: ☐ Google ☐ Facebook ☐ Website ☐ Sign Board ☐ Self Search ☐ Other:

☐ Friend/Family Whom may we thank?

Medical History

Please answer all the following questions as accurately as possible.

Date of your last physical examination:

Are you presently under the care or supervision of a physician:☐Yes ☐No

What conditions/concerns are they treating:

Has there been any major changes in your health in the last 2 years? ☐ Yes ☐No

Please explain:

Have you ever been hospitalized? ☐ Yes ☐No

What was the reason for your hospitalization:

Have you ever had a surgery/operation or serious illness? ☐ Yes ☐No

Please explain:

Please list any current or past medical conditions in which you have had:

Please list ALL Medications, Herbs, Supplements, Inhalers, Birth Control, and recreational drugs you take:

List here ☐None

Do you take any erectile disfunction or performance medications?☐Yes ☐No

Do you take any blood thinners?☐Yes ☐No

Do you have a prescribed EpiPen? ☐Yes ☐No

Please list ALL allergies including environmental:

Please list any food sensitivities or intolerances:

Have you ever had an unusual reaction to anesthetic or dental freezing?☐Yes ☐No

Have you ever had a head/neck injury? ☐Yes ☐No

Please explain:

Date of last injury:

Do you have any (please check all that apply) of the following:

☐Heart condition ☐Heart murmur ☐Mitral valve prolapse ☐Shortness of Breath ☐Angina, ☐Sinus Rhythm, ☐High blood pressure ☐ Low blood pressure ☐Stents ☐Artificial Valves ☐Bypass Surgery ☐ Chest Pain

Have you ever had a heart attack or stroke? ☐ Yes Date: ☐No

Do you have any artificial joints or valves? ☐Yes ☐No

Date placed:

Do you have a pacemaker or implanted defibrillator?☐Yes ☐No

Date placed:

Do you ever experience dizziness, lightheaded or Fainting? ☐ Yes ☐No

Do you bleed excessively from a cut or injury or bruise easily? ☐Yes ☐No

Do your ankles, feet or hands swell? ☐ Yes ☐ No

Have you lost or gained weight recently? ☐ Yes and How much:+/- ☐ No

Do you ☐snore, ☐have trouble falling asleep or ☐staying asleep? ☐No

How many hours do you sleep on average per night?

How many times do you wake during the night (including washroom visits)?

How may hours do you typically get of sleep per day (naps)?

Medical History Continued…

Do you/Did you

☐Smoke ☐Vape ☐Use Marijuana ☐Use Other Recreational Drugs

How often/quantity:

Do you plan on quitting? ☐Yes ☐No

When did you quit?

When is your expected quit date?

☐Drink Alcoholic Beverages

How often per week/quantity:

☐None of the above

Are you currently dependant or have been in the past to Drugs/Alcohol/Smoking?☐Yes ☐No

Is there any chance you are currently pregnant or breastfeeding? ☐Yes ☐No

Due date:

Are you currently trying to get pregnant?☐Yes ☐No

Do you have any family history of the following: ☐Heart Attack ☐Stroke ☐Cancer ☐Diabetes ☐Other:

Do you have or ever had (please check all that apply):

☐HIV/AIDS, Lupus, Hodgkin’s, Mono ☐Hearing difficulties or Impairment ☐Insomnia ☐Eating Disorder (Anorexia, Bulimia) ☐Herpes/Cold Sores ☐Chemotherapy or Radiation Therapy ☐Heart Disease or Attack ☐Epilepsy or Seizures ☐Stomach/Intestinal Problems ☐Venereal Disease (STI/STD) ☐Urinary Tract Infections	☐Hepatitis (A, B, C) ☐High/Low Blood Pressure ☐Stroke, TIA ☐Mitra Valve Prolapse ☐Anemia ☐Fainting or Dizzy Spells ☐Diabetes ☐Cortisone/Steroid Therapy ☐Tuberculosis ☐Sinus Condition ☐Bladder Conditions	☐Respiratory Condition ☐COPD ☐Bronchitis ☐Asthma ☐Nervous Disorders ☐ADHD/ADD ☐Neurological Disorders ☐Autism ☐Vision Impairment ☐ Migraines ☐Gout	☐Rheumatic Fever/Scarlet Fever ☐Arthritis ☐Rheumatism ☐Osteoporosis ☐Kidney Disease ☐Thyroid disease ☐Cancer ☐Hormone Therapy ☐Ulcers ☐Sleep Apnea ☐ Acid Reflux/Heartburn

Please let us know if you have had any past/present traumatic events in which you do not want to discuss in person prior to your appointment. E-mail is confidential aspecthygiene@outlook.com and can be discussed at your pace in the comfort of your own environment before coming in for your appointment with us.

Is there anything else you think we need to know or understand about your medical health?

Dental History

When was your very last dental visit?

Date of last X-rays:

Date of last dental exam (DDS/RDH):

Date of last dental hygiene appointment:

Do you currently have a regular dental office you attend for routine examinations?☐Yes ☐No

What is your Dentist’s Name?

Practice location:

Practice telephone number:

Do you wish to continue seeing this office for your yearly examinations?☐Yes ☐No

What is one thing you really enjoyed about your last dental office and one thing they could have improved upon?

Do you have dental anxiety or comfort requests?

Please rank your level of dental anxiety from 1-10 (10 being extremely high):

Have you had a traumatic dental experience in the past?☐Yes ☐No

Is it ok if your hygienist asks you for more details about this event? ☐Yes ☐No

How can we make your appointment more comfortable?

Dental History Continued…

What is your main concern with your oral health at this time?

Do you use ☐Electric Toothbrush ☐Manual Toothbrush ☐Both

Do you have any of the following oral habits? ☐None

☐Cheek/Lip/Tongue Biting ☐Grinding/Bruxism ☐Mouth Breathing ☐Tongue Thrusting ☐Nail Biting ☐Excessive gum chewing ☐Chewing on items like Pens, Pencils, Straws ☐Finger/Thumb Sucking ☐Clenching

Please check all that apply to you:

☐Dry Mouth ☐Difficulty swallowing ☐Tongue Tied ☐Cold sores ☐Canker Sores ☐Burning Tongue ☐Oral Piercings/Tattoos ☐Broken or Missing Teeth ☐Sore Jaw	☐Stained Teeth ☐Bad Breath ☐Cavities ☐Spaced or Crooked teeth ☐Loose Teeth ☐Bleeding gums ☐Sore gums ☐Sensitive teeth ☐Tonsil stones	☐Growths or Spots in the Mouth ☐Frequent Earaches ☐Unexplained nose bleeds ☐Popping/Clicking in the Jaw ☐Neck/Shoulder pain ☐Headaches ☐Difficulty Breastfeeding (infants) ☐Gagging ☐Unsatisfactory dentures

Have you ever had?

Periodontal Treatment ☐Yes ☐No

Orthodontic Treatment ☐Yes ☐No

Oral Surgery ☐Yes ☐No

Your bite adjusted/ground ☐Yes ☐No

Dental Implants ☐Yes ☐No

Night Guard ☐Yes ☐No

Dental sedation ☐Yes ☐No

How often do you:

Brush your teeth:

Floss your teeth:

Mouth rinse:

Whiten Your teeth:

Toothpaste you typically use:

Are you happy with the appearance of your teeth? ☐Yes ☐No

If no, what would you like to see changed?

I, the undersigned, certify that I have provided an accurate and complete personal medical and dental history and that I have not knowingly omitted any information. I have had the opportunity to ask any questions and receive answers to any questions regarding the medical or dental history prior to its completion. Should there be any changes to my health status and or any other information I have provided, I will advise Aspect Hygiene office immediately. I authorize Aspect Hygiene to discuss with me and perform an assessment as may be required to determine any necessary treatment. I understand that the information I have provided and additionally collected in my appointments may be discussed, with my consent, with my primary physician and any other member of my health care team. I have been advised of and read the Privacy Policy of this office and understand that my personal information will be collected, used, and disclosed within the guidelines of this policy. Aspect Hygiene professional services are rendered to you and not your insurance company. I understand that the responsibility for payment of services for myself and my dependants are solely mine, and I assume responsibility for payment of fees associated with these services. I understand that payments are required day of service unless otherwise stated in a formal payment arrangement.

Name: Relationship to Client:

Signature:________________________________ Date:

Reviewed by Treating Hygienist: Date: ________________________

Please email your Client Intake form for your appointment to email address: aspecthygiene@outlook.com. If unable to email please print and bring filled out to your appointment or come to your appointment 15 minutes early to fill out in office.